HX64063852 
RD540  M36  The  surgical  treatme 


RECAP 


WOUNDS  AND  OBSTRUCTION 

OF  THE  [NTESTTOS. 


MARTIN  AND  HARE. 


Columbia  WinMvUit^ 
in  tije  Citp  of  Mfto  |9orfe 

College  of  ^fjj'Siciang  anb  ^urgeonsf 


3^ef  erence  l^ibrarp 


TPIE 


SURGICAL  TREATMENT 


WOUNDS  AND  OBSTRUCTION 


INTESTINES. 


BY 

EDWARD  MARTIN,  M.D., 

INSTRUCTOE    IN    OPEEATIVE  SURGERY  UNIVERSITY  OF    PENNSYLVANIA, 

SURGEON  TO  THE  HOWARD  HOSPITAL, 

ASSISTANT  SURGEON  TO  THE  UNIVERSITY  HOSPITAL, 


/v. 


CLINICAL  PROFESSOR  OF  DISEASES    CTi  CHILDREN  AND  DEMONSTRATOR  OF 

THERAPEUTICS  IN  THE  UNIVERSITY  OF  PENNSYLVANIA, 

PHYSICIAN  TO  ST/ AGNES  HOSPITAL. 


liCl^l 


'Mjs_ 


PHILADELPHIA: 

W.   B.   SAUNDERS, 

913  Walnut  Street, 
1891. 


PHILADELPHIA : 

COLLINS  PRINTING  HOUSE, 

705  JAYNE  STREET. 


TO 

D.  HAYES  AGNEW,  M.D.,  LL.D., 

PRESIDENT    OF    THE    COLLEGE    OF    PHYSICIANS    OF    PUILADELPHIA  ; 
HONORARY    PROFESSOR    OF    SURGERY    IN    THE    UNIVERSITY    OF    PENNSYLVANIA, 

AS   A   TRIBUTE    OF    AFFECTION   AND    EESPECT 

BY  TWO 

OF  THE  MANY  YOUNG  MEN  HE  HAS 
BEFRIENDED. 


PREFACE 


In  presenting  this  essay  upon  the  Surgical  Treatment  of  Wounds 
and  Obstruction  of  the  Intestines  to  the  Trustees  of  the  Fiske 
Fund,  it  is  proper  to  outline  the  scope  of  our  work  and  to  state 
briefly  the  facts  and  lines  of  original  research  upon  which  our 
conclusions  are  based.  For  over  two  years  we  have  made  experi- 
ments in  the  laboratory  upon  these  subjects,  and  have  carried  out 
with  every  detail  all  the  methods  and  modifications  of  operations 
that  have  been  published,  or  which  occurred  to  us  in  the  course  of 
our  own  studies.  It  is  for  this  reason  we  feel  some  confidence 
that  the  opinions  expressed  by  us  in  the  following  pages  are  not 
without  a  firm  basis,  and  that  they  are  stated  with  the  positiveness 
of  one  who  is  sure  of  the  ground  on  which  he  stands. 

In  addition  to  the  original  work  involved  in  studying  so  impor- 
tant a  branch  of  surgery  as  the  one  before  us,  and  which  will  be 
found  represented  graphically,  in  part  at  least,  by  a  number  of 
tracings,  we  have  collected  and  placed  before  the  reader  what  we 
believe  to  be  the  fullest  statistics  yet  collected  upon  gunshot  wounds 
of  the  abdomen. 

Our  tables  of  intestinal  obstruction  fully  recorded  in  the  original 
manuscript  we  have  summarized,  appending  to  the  various  forms 
of  acute  obstruction  the  result  of  analysis  of  our  own  cases. 


CONTENTS. 


Introduction.     Intestinal  Obstruction 


PAGE 


Chapter  I. 
II. 
III. 
IV. 
V. 
YI. 
YII. 
YIII. 
IX. 

X. 

XI. 

XII. 

XIII. 

XIY. 


Congenital  Malformations 19 

Intussusception 28 

Internal  Strangulation 40 

Yolvulus 4Y 

Obstruction  from  Foreign  Bodies 52 

Intestinal  Paralysis ~ 51 

Chronic  Obstruction 63 

Peritonitis       66 

On  Diagnosing  the  Yarious  Forms  of  Intestinal 

Obstruction 81 

On  the  General  Treatment  of  Intestinal  Obstruc- 
tion     86 

Special  Treatment  of  Obstruction 90 

Surgical  Treatment  of  Intestinal  Obstruction  .     .   107 

Wounds  of  the  Intestines 122 

Rupture  of  the  Intestines 140 


Cases  of  Celiotomy  for  Gunshot  Wounds  of  the  Abdomen 
Summary  of  the  Tables  of  Gunshot  Wounds  of  the 


145 


Abdominal  Contents 164 


Index 167 


WOUNDS  AND  OBSTRUCTION  OF  THE  INTESTINES. 


INTRODUCTION. 

INTESTINAL  OBSTRUCTION. 

Under  the  heading  of  intestinal  obstruction  are  commonly  classed 
not  only  such  conditions  as  strangulation,  Avhich  by  a  direct  primary 
effect  i^roduces  a  mechanical  impediment  to  the  outward  passage  of 
the  intestinal  contents,  but  also  certain  pathological  states,  as  peri- 
tonitis or  enteritis,  which,  by  engendering  a  paralytic  condition  of 
the  intestinal  walls,  favors  primarily  stasis,  with  resultant  fermen- 
tation of  the  contained  matter  and  the  development  of  the  t}'pical 
symptoms  of  obstruction,  accompanied  by  those  of  either  inflam- 
mation or  septic  absorption. 

From  the  clinical  standpoint  all  authors  agree  in  classifying  the 
cases  of  intestinal  obstruction  under  the  headings  acute  and  chronic, 
though  no  sharp  distinctive  line  can  be  draAvn  between  the  two, 
and  either  is  liable  to  merge  into  the  other. 

The  further  general  classification  of  conditions  causing  acute 
intestinal  obstruction  is  as  follows  : — 

1.  Congenital  malformations. 

2.  Invagination,  or  telescoping  of  one  portion  of  the  bowel 

within  another. 

3.  Internal  strangulation,  by  bands,  diverticula,  membranous 

adhesions,  through  apertures,  or  by  means  of  the  abnor- 
mal attachments  of  organs  not  in  themselves  diseased. 

4.  Volvulus,  or  twisting  of  the  bowel. 

5.  Impaction  of  foreign  bodies,  gall-stones,  etc. 

To  these  headings  should  be  added  still  another,  namely : — 

6.  Obstruction  from  intestinal  paralysis  and  distention. 

2 


18  WOUNDS   AND   OBSTRUCTION   OF  THE   INTESTINES. 

The  caiiBes  producing  chronic  obstruction  are — 

1.  Stricture. 

2.  Neoplasms. 

3.  Pressure  of  tumors  external  to  the  boAvel. 

4.  Impaction  of  fecal  masses. 


CHAPTER  I. 

CONGENITAL   MALFORMATIONS. 

Under  this  heading  are  considered  anomalies  or  malformations 
of  the  bowel  itself  rather  than  of  its  environments,  though  upon  a 
fissure  or  defect  of  the  diaphragm,  or  upon  abnormal  persistence  of 
the  omphalo-mesenteric  duct,  may  depend  an  occlusion  no  less  abso- 
lute than  that  characterizing  closure  or  absence  of  a  part  of  the 
bowel. 

The  obstruction  is,  in  the  great  majority  of  cases,  dependent  upon 
malformation,  or  absence  of  the  rectum  or  anus. 

In  the  rare  cases  of  coarctation,  or  atresia  (ira perforation),  in  the 
continuity  of  the  intestinal  canal,  the  lesion  may  be  situated  at  any 
portion  of  the  alimentary  tract,  though  as  a  result  of  the  study  of 
many  cases  the  seats  of  preference  seem  to  be,  in  the  small  intes- 
tine, the  duodenum,  and  the  region  of  the  ileocsecal  valve ;  in  the 
large  intestine,  the  sigmoid  flexure. 

Apitz^  records  a  case  of  imperforation  of  the  oesophagus,  the  lat- 
ter ending:  in  a  blind  cul-de-sac.  Cases  of  atresia  at  or  about  the 
region  of  the  pylorus  are  on  record.  Turner^  describes  the  autopsy 
of  an  infant  in  which  there  were  two  portions  of  the  jejunum 
reduced  to  fine  impermeable  bands.  Pied^  has  observed  the  com- 
plete separation  of  the  duodenum  from  the  jejunum.  The  absence 
or  stricture  of  portions  of  the  ileum  (Blat.,*  Andrews,'  Loblig- 
eois®),  or  colon  (Cohen,'  Thomas,^  etc.)  has  been  occasionally 
recorded.  Thomas  notes  the  complete  absence  of  jejunum,  ileum, 
and  the  greater  part  of  the  colon. 

'  Allgemein.  Deutsch,  Hebammen.  Zeitung,  1. 

2  Edinburgh  Med.  Jour.,  1863^,  ix. 

3  Jour,  de  Med.  Chirurg.  et  Pharm.,  1802,  iii. 

*  Bulletin  Soc.  Anat.  de  Paris,  1849,  xxiv,  1856. 
5  Peninsular  Med.  Jour.,  Ann  Arbor,  1853-4. 

5  De  rOblit.  Congen.  des  Intestines,  4°,  Paris. 
7  Med.  Zeitsch.,  Berlin,  1838,  vii. 

*  Lancet,  London,  1884. 


20  WOUNDS   AND   OBSTRUCTION   OF   THE   INTESTINES. 

At  times  the  symptoms  of  obstruction  can  be  traced  to  a  stran- 
gulation, an  incarceration,  or  a  volvulus  due  to  malposition.  Price  ^ 
gives  an  instance  of  transposition  of  the  stomach  and  duodenum, 
with  the  colon  placed  behind  the  latter.  As  a  consequence  of  this 
the  colon  was  strano^ulatcd,  the  case  terminating:  fatallv. 

The  cause  of  congenital  coarctation,  or  atresia  of  the  intestinal 
canal,  is  usually  a  pre-natal  inflammation,  either  primarily  inter- 
fering with  growth,  or  by  the  deposit  and  organization  of  inflam- 
matory exudate,  producing  such  disturbance  in  nutrition  that  wast- 
ing and  contraction  take  place. 

It  is  of  importance  to  bear  in  mind  the  fact  that  the  stricture  or 
defect  is  in  many  cases  not  limited  to  one  part  of  the  bowel.^ 

The  more  common  congenital  formative  defects  of  anus  and 
rectum  are  classified  with  reference  to  the  method  of  development 
of  these  parts.  The  anal  opening  is  continued  upward  until  it 
finally  unites  with  the  rectum  in  its  downward  extension.  From 
arrested  development,  or  inflammation,  there  may  be  narrowing 
(partial  occlusion),  atresia  (complete  occlusion),  or  absence  (imper- 
foration)  of  anus,  of  rectum,  or  of  both  these  structures.  Again, 
there  may  be  a  stenosed  opening  in  an  abnormal  position.  Good- 
man^ reports  a  case  of  imperforate  anus  and  rectal  atresia  unsuc- 
cessfully treated  by  colotomy,  in  which,  at  the  autopsy,  the  rectum 
was  found  to  communicate  by  means  of  a  minute  orifice  with  the 
urethra  at  the  base  of  the  Caput  Gallinaginis. 

The  frequency  of  associated  narrowings  in  other  parts  of  the 
alimentary  canal  must  be  considered  in  dealing  with  these  abnor- 
malities. A  child  operated  upon  by  Darien  *  for  imperforate  anus 
was,  at  the  autopsy,  found  to  have  a  dilatation  of  the  duodenum, 
imitating  a  second  stomach;  this  was  due  to  occlusion  on  the  intes- 
tinal side  by  a  complete  spiral  valve. 

Symptoms. — The  symptoms  of  obstruction  dependent  upon  con- 
genital stenosis,  or  atresia  of  the  intestinal  canal,  are,  of  course,  not 
developed  until  after  birth,  and  the  taking  of  food  by  the  mouth. 
They  do  not  difl^er  from  those  of  acute  obstruction  dependent  upon 
other  causes.     There  is  no  passage  of  fecal  matter  from  the  anus ; 

1  Am.  Jour.  Med.  Sc,  1853. 

2  Gaertner,  Jahrb.  f.  Kinderheil,  1883. 

3  Medical  Register,  Feb.  25,  1888.  *  Bull  Soc.  Auat.  de  Par.,  1881,  Ivi. 


COXGENITAL   MALFORMATIONS.  21 

there  is  obstinate  and  continued  vomiting  of  all  food  taken  ;  this 
vomited  matter  is  more  or  less  feculent  in  odor  and  appearance, 
depending  upon  the  seat  of  obstruction  and  the  time  which  has 
elapsed  since  the  symptoms  developed.  There  is  often  violent 
peristalsis  to  be  detected  through  the  belly  walls.  There  may  be 
much  tympany.  Symptoms  of  pain,  and  straining  efforts  at  defe- 
cation are  common.  Death  is  inevitable  if  the  case  is  not  treated 
surgically. 

The  immediate  cause  of  the  fatal  issue  is  inanition  or  exhaustion. 
Perforative  peritonitis  occurs  at  times,  but  is  not  so  common  as  in 
acute  obstruction  of  a  more  advanced  age. 

"With  such  symptoms  following  hard  upon  birth,  the  diagnosis  of 
obstruction  from  either  congenital  malformation  or  internal  stran- 
gulation would  be  positive,  and,  as  either  would  demand  the  same 
treatment,  the  differential  diagnosis  between  these  two  is  not  abso- 
lutely essential. 

Diagnosis. — Since  the  most  common  seat  of  this  form  of  con- 
genital malformation  is  about  the  anus  and  rectum,  a  careful  search 
should  be  made  in  this  region,  the  finger  being  carried  into  the  anal 
aperture,  if  patulous,  in  the  hope  of  finding  the  seat  of  occlusion. 
By  means  of  a  bougie,  exploration  can  be  carried  some  inches  fur- 
ther than  the  finger  can  reach. 

It  must  be  remembered  that,  the  rectum  and  anus  being  normal, 
the  next  probable  seats  of  obstruction  are  at  or  about  the  duode- 
num, the  ileocecal  valve,  or  the  sigmoid  flexure  of  the  colon. 

In  the  new-born  child  the  colon  is  a  foot  in  length,  and  normally 
occupies  the  same  anatomical  region  as  in  the  adult.  The  sigmoid 
flexure  is  ten  inches  long,  and  lies  mainly  in  the  pelvis. 

The  condition  of  the  colon  can  readily  be  made  manifest  by 
means  of  injection  of  either  air,  hydrogen,  carbonic  acid  gas,  or 
any  unirritating  liquid,  preferably  normal  saline  solution  (.7  per 
cent.).  Neither  gas  nor  liquid  should  be  passed  into  the  bowels  by 
means  of  a  force-pump,  or  any  kind  of  injecting  syringe. 

If  gas  is  used  it  should  be  passed  from  a  bag,  and  the  pressure, 
not  exceeding  a  pound  and  a  half,  should  be  kept  under  observa- 
tion by  means  of  a  manometer  attached  to  the  supply  tube. 

The  best  way  of  introducing  water  is  by  means  of  gravity.  The 
ordinary  fountain  syringe  answers  every  purpose;  the  nozzle  should 


22  WOUNDS    AND    OBSTRUCTION    OF   THE   INTESTINES. 

be  wrapped  tiglitly,  an  inch  and  a  half  from  its  extremity,  witli  a 
narrow  roller  bandage,  thus  forming  a  shoulder  which  can  be 
pressed  against  the  anus,  preventing  a  premature  discharge  of  the 
injected  liquid.  Tiie  receiving  bag  should  not  be  elevated  more 
than  three  feet  alcove  the  level  of  the  patient.  This  gives  a  pres- 
sure of,  approximately,  one  and  a  half  pounds  to  the  square  inch, 
and  is,  in  all  probability,  sufficient  to  overcome  the  resistance  of 
the  ilcocsecal  valve,  if  steadily  and  continuously  applied. 

By  either  gas  or  liquid  injection  the  colon,  if  permeable,  can  be 
distinctly  and  unmistakably  outlined,  and  by  slightly  increasing  the 
pressure  (three  pounds)  the  ileocsecal  valve  may  be  made  to  yield, 
if  healthy.  If  the  colon  is  not  permeable  throughout  its  whole 
extent,  the  point  where  the  injection  is  arrested  is  at  once  demon- 
strated. 

The  quantity  of  liquid  required  to  fill  the  extent  of  the  colon 
permeable  from  below  is  also  of  diagnostic  significance,  since,  if  it 
be  but  an  ounce  or  two,  the  obstruction  must  be  low  down,  while 
if  many  ounces  are  received,  this  indicates  a  seat  much  nearer  the 
ileocsecal  valve. 

The  character  of  the  vomit  would  probably  suggest  the  location 
of  atresia  at  or  near  the  pyloric  valve.  In  addition  to  this,  where 
the  atresia  is  located  in  this  region,  the  tympany  is  mainly  confined 
to  the  epigastric  region,  the  lower  part  of  the  bowel  by  contrast 
appearing  to  recede. 

The  passage  of  the  injection  through  the  ileocsecal  valve  for  the 
further  localization  of  the  seat  of  obstruction  is  not  to  be  recom- 
mended in  this  relation,  since  the  information  to  be  derived  from 
it  is  of  little  value,  and  it  is  a  method  which  might  produce  serious 
results  upon  the  delicate  intestinal  walls  of  children. 

Prognosis. — If  the  case  is  not  treated  surgically,  the  prognosis 
is  absolutely  unfavorable.  That  there  is  a  possibility  of  nature 
effecting  a  cure,  under  certaiu  circumstances,  is  shown  by  the 
remarkable  case  reported  by  Theremin,'  which,  though  finally  per- 
ishing, lived  for  six  months.  At  the  autopsy  the  upper  part  of  the 
duodenum  terminated  in  a  blind  pouch,  the  inner  surface  of  which 
was  so  deeply  invaded  by  an  ulcer  that  a  minute  opening  was 

1  Dent.  Zeit.  f.  Cliirur.,  viii.  3,  34. 


CONGENITAL    MALFORMATIONS.  23 

formed  into  a  cul-de-sao  of  the  ileum.  Practically,  death  is  certain, 
and  usually  occurs  on  the  third  day,  though  it  may  be  postponed 
till  the  fifteenth  or  twentieth  day. 

With  a  mortality  of  a  hundred  per  cent.,  for  expectant  treatment 
there  should  be  no  hesitation  in  resorting  to  the  knife,  but  even 
here  prospects  are  gloomy,  and  the  prognosis  must  be  distinctly 
unfavorable. 

Of  49  cases,  in  14  (28  per  cent.)  there  was  more  than  one  point 
of  obliteration. 

Of  37  more  elaborately  reported  cases,  malformation  was  so  great 
in  4  that  no  operation  could  possibly  avail.  In  10  enterotomy  and 
the  establishment  of  an  artificial  anus  would  have  been  indicated ; 
in  20,  as  far  as  the  anatomical  relations  were  concerned,  a  lateral 
approximation  might  have  been  practised. 

Putting  aside,  for  the  moment,  the  risk  attendant  upon  laparo- 
tomy as  pei'formed  upon  such  young  children,  the  operation  will, 
from  these  figures,  be  inevitably  unsuccessful  in  10  per  cent,  of 
cases,  and  can  accomplish  nothing  more  satisfactory  than  an  arti- 
ficial anus  in  21  per  cent. 

Treatment.— Having  located  the  seat  of  obstruction  in  the 
anus,  the  rectum,  some  portion  of  the  colon,  or,  these  parts  being 
normal,  somewhere  in  the  continuity  of  the  small  intestines,  the 
question  of  treatment  arises. 

This  should  invariably  be  operative.  Where  the  anus  is  com- 
pletely occluded  or  is  imperforate  the  condition  of  the  rectum,  or 
even  its  presence,  cannot  be  positively  ascertained,  though  a  bulg- 
ing in  the  ischio-rectal  region,  observed  during  straining  or  crying, 
would  denote  a  eul-de-sac  of  bowel  not  far  from  the  surface.  It  is 
universally  agreed  that  in  these  cases,  unless  the  cause  of  obstruc- 
tion be  simply  a  membrane  or  a  thin  wall  of  tissue,  a  careful 
search  should  be  made  for  the  gut,  carrying  the  incision  into  and 
through  the  anatomical  region  in  which  the  bowel  should  lie.  The 
obliquity  of  the  pelvis  in  children  must  be  borne  in  mind  by  the 
operator,  and  since  it  exhibits,  compared  to  the  size  of  the  child, 
very  small  measurements,  from  the  top  of  the  coccyx  to  the  pubic 
symphysis  but  little  more  than  an  inch,  Verneuil  has  proposed 
resection  of  the  coccyx  in  these  cases  as  a  means  of  giving  room  in 


24  "WOUXDS    AND    OBSTRUCTION    OF   THE   INTESTINES. 

the  directiou  in  which  the  search  should  be  carried,  i.  e.,  backward 
and  upward. 

If  the  rectum  is  found,  it  should  be  brought  down  to  the  skin 
wound  and  stitched  in  place.  Allingham  distinctly  advises  against 
the  latter  procedure  on  the  ground  that  it  prolongs  the  operation, 
that  the  stitches  cut  out,  as  a  rare  exception  only,  effecting  the 
object  for  which  they  are  placed,  and  that  the  formation  of 
abscesses  is  more  common;  but  it  not  only  has  received  the  coucur- 
rence  of  Amussat,  of  Verneuil,  and  of  the  profession  at  large,  but 
is  more  in  the  line  of  modern  antiseptic  work,  seems  rational,  and 
has  to  its  credit  many  brilliant  successes. 

If  the  rectum  cannot  be  found  by  this  incision,  followed  by  cai'e- 
ful  dissection  upwards  and  backwards  to  the  depth  of  an  inch,  or 
an  inch  and  a  half,  the  cut  for  left  inguinal  colotomy  should  be 
made.  If  the  finger,  passed  into  the  peritoneal  cavity,  shows  that 
the  perineal  incision  can  be  safely  deepened,  with  a  condition  of  the 
rectum  which  will  allow  of  its  being  drawn  through  the  opening, 
the  operation  first  undertaken  should  be  completed,  and  the  peri- 
toneal incision  should  be  closed. 

If,  however,  the  conditions  are  such  that  an  attempt  to  form  a 
new  rectum  and  anus  is  inadmissible,  as,  for  instance,  where  there 
is  complete  absence  of  rectum  and  atresia  of  the  sigmoid  flexure, 
then  left  inguinal  colotomy  should  be  performed.  The  gut  should 
be  held  in  place,  after  suture  of  the  skin  to  the  parietal  peritoneum, 
by  a  piece  of  rubber  catheter  passed  across  the  wound  and  through 
the  mesentery  close  to  the  bowel,  or  by  a  harelip  pin,  as  described 
by  Kelsey,  used  in  a  similar  way,  except  that  it  transfixes  each 
edge  of  the  parietal  wound.  Stitches  should,  of  course,  be  added. 
Before  securing  the  bowel  in  this  way  a  digital  examination  should 
be  made  in  the  region  of  the  ileocsecal  value  and  the  duodenum, 
since  these  are  the  commonest  seats  of  congenital  malformation. 

Many  cases  have  been  illustrative  of  the  danger  of  depending 
upon  left  or  even  right  inguinal  colotomy  without  making  further 
exploration  of  the  abdominal  contents.  Depault'  formed,  by  means 
of  colotomy,  an  artificial  anus  in  the  case  of  a  child  suffering,  im- 
mediately after  birth,  from  obstructive  symptoms.  After  death  the 
ileum  was  found  to  end  as  a  cul-dc-sac  a  very  short  distance  from 
the  ileocsecal  valve.     Laborde^  performed  a  similar  operation,  but 

1  Gaz.  de  Hopit.,  1856.  2  Gaz.  de.  Par.,  1861. 


CONGENITAL   MALFORMATIONS.  25 

found  at  the  autopsy  a  complete  ocelusion  of  tlie  jejunum  nine  and 
one-half  inches  from  the  pylorus,  together  with  five  other  atresiie 
\  of  the  small  intestines. 

\  If  the  obstruction  is  found  to  depend  upon  an  atresia  of  neither 
anus  nor  rectum,  the  surgeon  should  advise  an  exploratory  abdomi- 
nal section  in  the  hope  of  finding  the  seat  of  trouble  and  remedying 
it  by  colotomy,  enterotomy,  or  lateral  anastomosis. 

Now  that  an  exploratory  abdominal  section  can  be  safely  per- 
formed, it  would  seem  rational  in  cases  of  imperforate  anus,  or 
rectum,  or  both,  where  there  was  no  succussion  or  bulging  to  be 
detected  in  the  ischio-rectal  region  during  crying  or  straining  efforts 
of  the  child,  to  at  once  enter  the  peritoneal  cavity  by  an  incision  as 
for  colotomy,  and  examine  the  condition  of  the  sigmoid  flexure  and 
rectum.  If  the  operation  from  below  Avere  then  practicable,  it  could 
be  rapidly  and  safely  performed,  the  operator  being  guided  by  the 
knowledge  obtained  by  his  exploratory  incision,  and  by  the  finger 
passed  from  above  to  the  seat  of  operation.  If  colotomy  were  indi- 
cated, it  could  be  performed  at  once.  This  would  save  the  pro- 
longed and  trying  dissection  necessitated  by  ignorance  as  to  the  seat 
and  condition  of  the  rectum  or  sigmoid  flexure. 

The  treatment  of  this  condition  by  trocar  and  canula,  with  sub- 
sequent dilatation,  has  little  to  recommend  it  beyond  the  ease  of  its 
application.  It  is  not  devoid  of  danger.  In  at  least  one  instance 
the  iliac  vein  was  wounded,  and  even  if  no  viscera  are  injured,  the 
outlet  thus  provided  is  insufficient. 

Though  the  mortality  of  abdominal  section  in  children  is  high 
the  operation  is  not,  as  is  the  disease  it  is  intended  to  combat,  abso- 
lutely fatal. 

In  case  of  invagination  the  snrgeon  has  far  more  right  to  hesitate, 
since  here  there  is  a  fair  percentage  of  spontaneous  cures  or  assisted 
cures  Avithout  operation.  In  congenital  occlusion  from  malforma- 
tion, however,  there  should  be  no  alternative. 

Nor  is  the  statement  that  children  are  easily  and  profoundly 
shocked  by  operative  procedures  entirely  true.  Chilling  and  loss 
of  blood  they  stand  not  at  all,  but  any  one  wdth  wide  experience 
in  the  treatment  of  their  diseases  is  frequently  astonished  at  the 
rapidity  with  which  they  react  from  tedious  and  severe  suro-ical 
operations,  provided  there  has  not  been  much  hemorrhage,  they 


26  WOUNDS    AND    OBSTRUCTION    OF   THE    INTESTINES. 

liavc  n(*t  been  ehilled,  and  tliat  the  aneesthetic  has  been  carefully 
administered. 

Griven  then  a  case  of  congenital  occlusion,  which  may  be  located 
in  any  pottion  of  the  small  or  large  intestines,  the  abdomen  must 
be  opened,  and  the  sooner  this  is  done  the  greater  are  the  chances 
of  success.  There  should  be  no  waiting  after  the  diagnosis  is 
clearly  established. 

If  the  constriction  is  in  the  colon  and  its  seat  has  been  recognized 
by  the  gas  or  water  test,  an  incision  in  this  region  is  indicated,  since, 
should  the  obliterated  portion  of  the  bowel  be  of  limited  extent  it 
could  be  carried  out  of  the  wound,  in  the  method  described  for  left 
inguinal  colotomy,  with  a  prospect  of  subsequently  closing  the  arti- 
ficial anus  thus  created  by  a  plastic  operation.  Or,  should  the  con- 
dition of  the  child  make  a  somewhat  more  prolonged  procedure 
justifiable,  the  continuity  of  the  colon  could  be  restored  by  a  colo- 
stomy. The  incision  for  exploration,  where  the  seat  of  obstruction 
is  not  known,  should  be  in  the  middle  line  of  the  belly,  either  just 
above  or  just  below  the  umbilicus. 

Bearing  in  mind  that  the  duodenum  and  the  ileo-csecal  valve  are 
the  regions  commonly  affected,  it  is  here  that  search  should  be  made. 
If  the  cause  of  trouble  is  found  at  the  duodenum,  gastro-  or  duodeno- 
jejunostomy will  be  indicated ;  if  at  the  ileo-csecal  valve  the  condi- 
tion of  the  patient  must  determine  the  choice  between  ileo-colostomy 
and  enterostomy.  If,  however,  there  are  multiple  seats  of  atresia, 
if  a  large  portion  of  the  intestinal  canal  is  atrophied  or  absent,  all 
operative  treatment  must  be  abandoned. 

Chloroform  should  be  used  as  an  ansesthetic  in  these  cases,  because 
it  is  not  followed  by  the  vomiting  which  characterizes  ether.  The 
abdominal  parietes  and  the  exposed  viscera  should  be  kept  warm 
by  means  of  light,  thin-ribbed,  rubber  hot- water  bags  at  110°  F., 
and  hot  flannel  cloths.  Every  endeavor  should  be  made  to  hasten 
the  operation. 

There  is  reason  to  believe  that,  should  this  method  of  treatment 
be  adopted,  some  cases  at  least  can  be  saved.  A  high  percentage 
of  cures  cannot  be  hoped  for,  but  each  successful  case  is  a  triumph 
to  surgical  skill. 

"When  no  operation  is  undertaken,  the  withdrawal  of  all  nourish- 
ment by  the  moutli,  the  administration  of  digested  nutrient  enemata 
by  the  bowel,  and  the  subcutaneous  injection  of  weak  solutions  of 
alcohol  (10  per  cent.)  should  be  advised. 


CONGENITAL   MALFORMATIONS.  27 


SUMMARY. 


1.  The  congenital  malformations  which  cause  intestinal  obstruc- 
tion are  mainly  due  to  prenatal  inflammation,  and  may  involve 
any  portion  of  the  intestinal  canal, 

2.  Excepting  atresia  or  imperforation  of  the  anus  dnd  rectum, 
the  common  seats  of  this  malformation  are  at  or  near  the  ileocsecal 
valve;  in  the  duodenum,  or  at  the  juncture  of  the  duodenum  with 
the  jejunum ;  in  the  sigmoid  flexure  of  the  colon. 

3.  In  28  per  cent,  of  these  cases  the  malformation  is  multi]:)le, 
and  in  over  10  per  cent,  is  of  such  a  nature  (atrophy,  extensive 
obstruction)  that  it  is  mechanically  irremediable. 

4.  The  symptoms  are  those  common  to  obstruction  (absolute  con- 
stipation, fecal  vomiting,  pain,  and  tympany).  If  the  trouble  is  in 
the  colon,  its  seat  can  be  located  by  gas  or  water  injections ;  if  near 
the  pyloric  valve,  by  the  peculiar  epigastric  distention  and  the 
character  of  the  vomit.  The  prognosis  is  absolutely  bad,  death 
usually  taking  place  on  the  third  day,  though  life  may  be  prolonged 
for  Aveeks. 

5.  The  treatment  is  surgical.  For  imperforate  anus,  the  coccyx 
may  be  excised,  and  the  bowel  sought  for  by  cutting  upward  and 
backward.  If  this  fails,  or  as  a  first  resort  where  there  is  absence 
of  bulging  in  the  anal  region  when  the  child  cries,  the  incision,  as 
for  left  inguinal  colotomy,  should  be  made  with  digital  exploration 
of  the  regions  commonly  malformed.  If  the  conditions  justify  it, 
an  attempt  to  form  a  new  anus  and  rectum  in  the  normal  position, 
of  these  structures  should  be  made,  the  finger  from  above  being  used 
as  a  guide. 

Finally,  if  this  is  not  possible,  and  no  other  seat  of  narrowing 
has  been  found,  the  surgeon  should  resort  to  left  inguinal  colotomy. 

6.  Where  the  seat  of  obstruction  is  unknown,  exploratory 
abdominal  section  is  indicated,  followed  by  either  gastro-enteros- 
tomy,  entero-enterostomy,  entero-colostomy,  enterostomy,  or  colos- 
tomy, as  indicated  by  the  special  lesion  and  the  condition  of  the 
patient.  With  chloroform  as  an  anaesthetic,  attention  to  the  preser- 
vation of  the  body  heat,  and  rapidity  of  manipulation  in  complet- 
ing the  operation,  fair  results  may  be  expected. 


CHAPTER  II. 

INTUSSUSCEPTION. 

By  intussusoeption  is  meant  the  invagination  or  turning  of  one 
portion  of  the  gut  within  the  lumen  of  another  part  immediately 
adjoining. 

The  invagination  is  made  up  of  three  layers  of  bowel. 

The  intussusceptum  is  composed  of  the  entering  and  returning 
layers,  while  the  receiving  layer  constitutes  the  sheath  or  intussus- 
cipiens.  The  ring  formed  by  the  entering  layer  as  it  "is  turned 
sharply  upon  itself  to  form  the  returning  layer  is  called  the  apex. 
By  the  neck  is  meant  the  ring  which  results  from  the  flexure  formed 
by  the  returning  layer  as  it  merges  into  the  sheath. 

Classification. — Intussusception  is  usually  considered  under 
the  two  general  heads,  acute  and  chronic.  Bafinesque,  for  pur- 
poses of  clinical  study,  has  still  further  elaborated  this  classifica- 
tion into — 

1.  Ultra  acute,  death  taking  place  within  the  first  twenty-four 

hours. 

2.  Acute.     The  case  terminating  l^etween  the  first  and  seventh 

day. 

3.  Subacute.     Lasting  one  month  and  upward. 

The  invagination,  if  named  from  its  seat,  is  termed — 

(a)  Enteric,  involving  the  small  intestines  only. 

(b)  Ileocecal,  in  which  the  ileum  and  csecum,  together  with 

the  ileocsecal  valve,  are  turned  into  the  colon. 

(c)  Ileocolic.     In  this  the  ileum  is  prolapsed  through  the  ileo- 

C£ecal  valve,  the  latter  retaining  its  proper  position  till,  as 
a  result  of  secondary  changes,  it,  together  with  the  cjecum, 
is  more  or  less  displaced. 

(d)  Colic.     The  invagination  involves  the  colon  only. 

(e)  Rectal.     Here  the  seat  qf  trouble  is  situated  entirely  within 

the  rectum. 


INTUSSUSCEPTION.  20 

Usually  the  upper  segment  of  the  gut  is  received  into  the  lower ; 
where  the  reverse  condition  obtains  it  is  called  retrograde  intussus- 
ception, Kokitansky,*  Harrison,  Ulnier  and  others  have  reported 
cases.  This  was  observed  in  1,5  per  cent,  of  Leichtenstern's  593 
cases,  and  occurred  in  both  the  small  and  large  intestines.  As  a 
secondary  effect  of  a  descending  invagination  there  may  be  formed 
a  retrograde  intussuscei^tion  which,  involving  the  sheath  of  the 
former,  surrounds  the  intussusception  with  five  layers  of  gut. 
Spry^  and  Stainet^  state  that  this'  is  due  to  a  loose  intussuscii)iens 
which  becomes  folded  upon  itself,  Leichtenstern  states  that  this  is 
observed  only  in  the  colon. 

Double  and  triple  intussusceptions  have  been  occasionally  noted. 
In  these  cases  the  intussusception  plays  the  part  of  a  foreign  body, 
thus  producing  reduplications  of  its  encircling  sheaths.  It  must  be 
remembered  that  these  invaginations  are  double  and  triple  only  in 
a  very  limited  portion  of  their  length. 

Causes  of  Intussusception. — The  cause  of  chief  importance 
is  irregularity  in  the  nervous  mechanism  of  the  intestines,  which 
allows  of  a  sudden  spasmodic  contraction  of  a  portion  of  the  bowel, 
while  its  adjoining  continuation  may  be  entirely  relaxed.  This 
would  seem  to  account  for  the  intussusceptions  so  often  observed 
upon  the  autopsy  table,  and  which,  there  is  every  reason  to  believe, 
developed  either  during  or  immediately  after  the  death  struggle. 
These  invaginations  are  frequently  multiple  and  very  limited  in 
extent,  and  exhibit  none  of  the  effects  of  venous  congestion,  obstruc- 
tion, or  inflammation.  The  facts  that  obstructive  invagination 
occurs  in  children,  is  associated  with  colic,  is  observed  after  abdom- 
inal injuries,  and  sometimes  follows  typhoid  fever  or  enteritis,  would 
all  strongly  suggest,  as  a  probable  causative  factor,  disordered  inner- 
vation. 

Nothnagle^  has  elaborately  studied  this  question  from  an  experi- 
mental standpoint.  By  means  of  the  faradic  current  he  vigorously 
stimulated  a  small  portion  of  the  bowel.  At  the  point  of  stimula- 
tion the  bowel  became  so  firmly  contracted  as  to  lose  its  natural 
color,  this  contraction  was  continued  upward  for  some  distance,  and 

1  Praktisclie  Heilk,,  1S73-4,  2  Lond.  Med.  Journ.,  vol.  iii, 

s  Bull,  de  la  Soc.  Anat.  de  Far.,  1850,  p.  314. 

*  Beitrage  zur  Physiologie  niid  Pathol,  des  Darm.,  p.  42.    Berlin,  1884. 


30  WOUNDS    AND    OBSTRUCTION    OF   THE    INTESTINES. 

not  infrequently  slight  temporary  retrograde  intussusception  was 
observed,  from  the  relaxed  portion  of  the  bowel,  which  was  not 
influenced  by  the  electric  current,  slipping  down  somewhat  over 
the  upper  portion  of  the  seat  of  contraction.  From  immediately 
below  the  seat  of  firm  contraction  the  bowel  was  observed  to  ascend 
in  the  form  of  a  sheath,  thus  producing  a  descending  invagination 
M^hich  progressively  increased  till  the  stimulation  was  removed, 
when  nervous  control  being  regained,  the  intussusception  under- 
went spontaneous  resolution.  Nothnagle  further  asserts  that  stim- 
ulation of  the  bowel  above  the  intussusception  is  without  effect,  but 
if  the  electric  current,  or  any  sufficient  stimulus  be  applied  below 
this  point,  the  parts  are  promptly  restored  to  their  normal  position 
by  the  ascending  contraction. 

We  have  made  repeated  experiments  on  dogs  to  confirm  I^oth- 
nagle's  conclusions,  but  our  results  varied  greatly  from  those  he 
has  published. 

We  readily  produced  the  firm  ring-like  contraction  of  the  bowel 
segment  to  which  the  current  was  applied,  but  observed  no  attempt 
at  invagination.  To  a  Dubois-Reymond  coil  connected  with  two 
cells,  and  drawn  out  to  twenty  on  the  scale,  were  attached  the 
electrodes.  The  segment  of  bowel  stimulated  was  not  upwards 
of  a  quarter  of  an  inch  in  length.  The  current  was  used  in  all 
strengths,  but  without  other  effect  than  a  local  spasm  so  violent  as 
to  make  the  area  involved  resemble  cartilage  both  in  appearance 
and  to  the  touch. 

As  other  causes  of  invagination,  secondary  or  exciting  in  their 
nature,  may  be  mentioned,  ingesta  (28  cases  in  593),  polypi  (5  per 
cent,  of  Leichteustern's  cases  were  dependent  upon  this  cause), 
inflammatory  affections  of  the  bowels,  traumatism  (263  cases  out 
of  593),  and  exposure  to  cold. 

Pathological  changes. — Cruveilhier  and  Gorham  have  observed 
that  there  is  strong  reason  for  believing  that  in  many  cases  of  severe 
colic,  especially  when  dependent  upon  imprudent  diet,  slight  tem- 
porary invagination  is  of  frequent  occurrence.  This  form  probably 
resembles  that  called  by  the  Germans  agonie  invagination,  and 
found  so  frequently  upon  the  autopsy  table. 

In  the  marked  cases  of  invagination,  profound  pathological 
changes  take  place.  As  the  intussusception  increases  at  the  expense 
of  the  intussuscipiens  the  mesentery  is  subject  to  constantly  in- 


INTUSSUSCEPTION.  31 

creased  tension  ;  as  a  result  of  this,  the  whole  of  the  involved  gut 
and  particularly  the  intussusceptum  assumes  a  sickly-shapfjd  curve, 
with  its  concavity  toward  the  mesentery.  The  opening  of  the  in- 
tussusceptum becomes  simply  a  slit  and  is  turned  inward  away  from 
the  lumen  of  the  bowel.  This  incurvation  involves  the  colon  only 
slightly,  and  the  rectum  not  at  all ;  when  marked  it  is  undoubtedly 
a  factor  in  producing  obstruction,  with  its  attendant  symptoms. 

That  invagination,  in  itself,  does  not  entirely  occlude  the  lumen 
of  the  bowel  is  shown  by  the  record  of  cases  where  life  has  been 
prolonged  for  weeks  and  months.  The  other  causes  operative  in 
producing  obstruction  are;  the  lodgment  of  undigested  food,  of 
hardened  fseces,  or  of  a  foreign  body,  and  swelling  of  the  involved 
area  from  venous  congestion  and  inflannnation  dependent  upon  the 
constriction  at  the  neck  of  the  sac.  There  is  usually  an  extrava- 
sation of  blood  into  both  the  mucous  membrane  and  the  mesentery ; 
inflammation  is  set  up  and  the  serous  surfaces  of  the  entering  and 
returning  layers  become  adherent  to  each  other.  Treves  states 
that  in  acute  cases  these  adhesions  are  more  frequently  absent  than 
present.  If  they  exist  and  are  extensive,  the  best  that  nature  can 
do  is  to  strengthen  the  growth  between  the  neck  and  upper  portion 
of  the  intussusceptum,  and  discharge  the  lower  portion  of  the  latter 
by  the  process  of  ulceration. 

The  sloughing  of  a  portion  of  the  intussusceptum  is  an  exceed- 
ingly common  termination  of  this  form  of  intestinal  obstruction. 
It  is  sometimes  discharged  as  a  tube,  but  more  commonly  in  the 
form  of  irregular  fragments.  The  extent  of  bowel  discharged  is 
at  times  extraordinary.  Dampier*  records  a  sloughing  bowel  seg- 
ment measuring  124  cm.  and  Bottcher,^  112  cm.  with  a  polyp  as 
the  causative  agent.  The  discharge  of  the  gangrenous  bowel  may 
be  the  first  sign  of  a  rapid  convalescence ;  if,  however,  the  mortifi- 
cation has  extended  in  the  direction  of  the  neck,  perforation  can  be 
expected,  with  a  resultant  peritonitis  w^hich  is  most  frequently 
diffuse. 

This  latter  complication  may  arise  without  perforation,  by 
extension  from  the  inflamed  and  strangulated  bowel,  acute  inflam- 
mation or  sloughing  of  the  mucous  membrane  so  affecting  the 

^  Med.  Trans.,  vol.  iv. 

2  Lobstein,  Anat.  Path.,  t.  1,  p.  146. 


32  WOUNDS   AND   OBSTRUCTION   OF   THE   INTESTINES. 

remaining  coats  of  the  bowel  that  tliey  are  readily  permeable  to 
septic  matter. 

Again,  cases  of  intnssusception  are  recorded  in  which  the  condi- 
tion has  lasted  for  ^^eeks  and  months  without  either  producing 
obstructive  symptoms  during  life  or  showing  adhesions  or  marked 
congestion  and  inflammatory  lesions  after  death. 

Frequency  of  occurrence. — In  a  total  of  1652  cases  of  intestinal 
obstruction,  hernia  excluded,  collected  by  Leichtenstern  and  Bryant, 
657,  or  approximately  40  per  cent.,  were  due  to  intussusception. 

In  regard  to  the  age  at  '\^llich  it  develops  all  authors  are  agreed 
that  it  is  most  frequent  in  the  first  year  of  life.  Of  Leichtenstcru's 
593  cases,  131  occurred  before  the  age  of  twelve  months  and  the 
great  majority  of  these  in  the  fourth,  fifth,  and  sixth  months.  The 
statistics  of  Smith,^  Hansen,^  and  Pitts^  absolutely  confirm  this. 
After  the  fifth  year  intussusception  becomes  comparatively  rare  till 
the  fortieth  or  fiftieth  year,  when  it  again  increases  in  frequency  of 
occurrence. 

The  ileocsecal  region  is  the  favorite  seat  of  invagination  at  all 
ages.  This  is  especially  marked  in  the  first  year  of  life,  when  this 
form  of  invagination  is  more  common  than  the  combined  sum  of 
all  the  others ;  the  ileum  invagination  being  exceedingly  rare. 
If  the  invagination  is  in  the  ileum,  the  lower  segment  of  this  por- 
tion of  the  bowel  is  its  common  position ;  if  in  the  colon,  it  will 
generally  be  found  at  the  sigmoid  flexure. 

Symptoms. — Depending  mainly  upon  the  amount  of  constriction 
.  at  the  neck  of  the  intussusceptum,  consequently  upon  the  amount 
of  congestive  swelling  and  bowel  obstruction,  the  intussusception  is 
classed  as  either  acute  or  chronic,  and  the  symptoms  of  each  form 
are  to  a  certain  extent  diiferent.  Also  the  symptomatology  of  in- 
tussusception in  the  infant  is  not  identical  with  that  of  the  adult  or 
old  man.  In  general  it  may  be  stated  that  the  first  symptom  of 
acute  intussusception  is — 

Pain. — Sudden,  violent,  diffuse ;  or,  if  localized,  usually  placed 
in  the  ileocsecal  or  umbilical  region.  After  a  few  hours,  in  chil- 
dren, a  much  longer  interval  in  the  adult,  the  pain  ceases,  often  as 

1  Amer.  Journ.  Med.  Sci.,  1S62. 

2  Dissertat.  Iii-aug.  Dorpat.,  1864. 

3  Jalirbuch  fur  Kinderlieil,  1870,  Bd.  3. 


INTTTSSUSCEPTION.  33 

suddenly  as  it  eommcnccd,  and  there  is  an  intci*val  in  which  there 
is  little  to  suggest  that  the  pathological  condition  still  continues. 
This  is  folloAved  by  a  return  of  tlie  pain,  the  paroxysms  becoming 
more  violent  and  prolonged,  the  intervals  less  marked  as  the  disease 
progresses,  or  in  the  adult  if  it  passes  into  the  chronic  form,  intervals 
of  even  days  may  elapse  between  the  paroxysms.  Tlie  pain  is  fre- 
quently accompanied  by  tenderness,  but  this  is  an  exceedingly 
variabl'e  symptom,  and  at  times  pressure  seems  to  relieve  the  pain. 

Vomiting. — This  is  practically  a  constant  symptom,  occurring 
with  the  sudden  pain,  or,  at  times,  even  preceding  it.  In  children 
it  continues  till  shortly  before  death  and  is  rarely  feculent. 

In  the  adult  and  in  the  chronic  form,  there  may  be  complete 
absence  of  vomiting,  though  this  is  certainly  exceedingly  rare. 
Leichtenstern  takes  exception  to  the  statement  that  the  seat  of  ob- 
struction is  indicated  by  the  period  at  which  vomiting  is  developed. 

The  ileum-invagination  is  most  frequently  accompanied  by  early 
vomiting,  not  because  of  its  seat,  which  is  usually  but  little  re- 
moved from  the  ileocsecal  valve,  but  because  it  is  commonly  ob- 
structive. The  vomiting,  both  in  time  of  development  and  in 
nature,  will  depend,  not  upon  the  seat  of  trouble,  but  upon  the 
presence  or  absence  of  obstruction,  and  may  be  early,  if  the  ob- 
struction is  absolute  in  the  sigmoid  flexure,  and  feculent  if  the 
bowel  is  occluded  in  the  upper  part  of  the  ileum. 

Blood-stained  mucous  evacuations. — This  symptom  is,  in  chil- 
dren, rarely  wanting.  Of  108  cases  of  invagination  in  the  first 
year  of  life  this  symptom  was  absent  in  but  four.  It  occurs  within 
a  few  hours  of  the  first  attack.  At  first  the  discharge  is  of  blood- 
stained feces ;  later,  if  obstruction  is  developed,  of  blood  and 
mucus,  and  is  usually  exceedingly  oifensive.  In  children,  diar- 
rhoea is  common  throughout  the  whole  course  of  the  case.  At 
times,  following  complete  constipation  and  feculent  vomiting,  there 
will  suddenly  appear  copious  evacuations  from  the  bowel,  mingled 
with  blood,  and  in  which  may  be  found  evidences  of  the  necrosed 
intussusceptum.  Where  this  slough  is  extensive  it  may  be  lodged 
in  a  lower  portion  of  the  bowel  and  cause  fatal  obstruction. 

Tenesmus. — In  connection  with  the  muco-sanguinolent  evacua- 
tions the  tenesmus  or  straining  is  a  symptom  so  common  that  it  is 
of  some  diagnostic  import.     That  it  is  not  dependent  upon  the 
character  of  the  evacuation  is  shown  by  the  fact  that  it  is  present 
3 


34  WOUNDS   AND    OBSTRUCTION    OF   THE    INTESTINES. 

in  cases  of  comjilctc  obstruction.  Brinton  has  shown  tliat  this 
symptom  is  seldom  developed  except  in  the  ileocseeal  and  colon 
invaginations. 

A  much  rarer  condition,  and  one  which  Leichtenstern  ascribes  to 
the  secondary  eflt'ect  of  intense  tenesmus,  is  a  j^^^'t^^fous  condition  of 
the  anus  due  to  paralysis,  and  dependent  upon  invagination  of  the 
descending  colon  and  rectum.  This  is  never  produced  by  invagi- 
nation of  the  ileum. 

Tumor. — Leichtenstern' s  statistics  show  that  a  tumor  can  be  felt, 
either  through  the  parietes  or  by  rectal  examination  in  52  per  cent, 
of  all  cases.  In  the  first  year  of  life  this  most  important  diagnos- 
tic sign  was  present  in  63  per  cent.  The  tumor  is  usually  felt  in 
the  left  iliac  region,  or  by  the  finger  passed  into  the  anus.  The 
ileocsecal  invagination  is  most  frequently  accompanied  by  demon- 
strable tumor ;  the  ileum  invagination  exhibits  this  symptom  with 
less  frequency. 

Many  authors  have  noted  that  the  tumor  varies  in  size  and  con- 
sistency from  time  to  time,  now,  during  an  acute  paroxysm  of  pain, 
being  hard,  knotty,  and  plainly  perceptible  shortly  afterward  eluding 
the  most  careful  search.  Duchaussoy  has  described  two  distinct 
movements  which  can  often  be  perceived  in  the  tumor,  namely,  the 
erectile  and  the  vermicular  motion. 

Distention  of  the  abdomen  is  not  of  great  significance,  because  so 
often  absent.  In  children  especially  it  may  appear  not  at  all,  or 
just  before  death.  In  adults,  where  obstruction  is  more  common, 
it  may  become  as  well  marked  as  in  obstruction  from  any  other 
cause. 

Dance'  calls  attention  to  an  inequality  in  the  shape  of  the  abdo- 
men dependent  upon  the  meteorism,  and  in  view  of  which  he  states 
that  the  seat  of  obstruction  can  often  be  inferred.  But  few  authors, 
however,  have  been  able  to  profit  by  his  observation. 

In  the  chronic  form  of  invagination  the  symptoms  are  less  vio- 
lent in  onset;  there  may  be  nothing  more  characteristic  of  the 
attack  than  recurring  paroxysms  of  pain,  meteorism,  and  obstruc- 
tion ;  with  symptoms  of  intestinal  stricture  constantly  manifesting 
themselves.  These  cases  terminate  either  in  cure  by  reduction  or 
by  extrusion  of  a  slough,  or  perish  from  exhaustion,  inanition,  or 

1  Rept.  gen.  d'anat.  et  de  pby.  Path.  bd.  i.     1826,  p.  206. 


INTUSSUSCEmON.  35 

in  the  course  of  an  acute  attack.     In  over  one-half  the  recorded 
cases  a  correct  diagnosis  was  not  made. 

Prognosis. — Leichtenstern  places  the  general  mortality  of  intus- 
susception as  treated  by  the  expectant  method  at  73  per  cent.  Pilz, 
Hansen,  and  Duchaussoy  arrive  at  a  similar  conclusion.  Our  own 
statistics  show  even  a  higher  rate  of  mortality  (90  per  cent.).  In 
the  first  year  of  life  this  mortality  is  much  higher,  mounting  to  88 
per  cent.,  and  death  commonly  occurs  between  the  fourth  and  sev- 
enth day.  Between  the  eleventh  aud  fiftieth  years  the  fatality  is 
less  (63  per  cent.),  and  the  duration  of  the  disease  is,  when  fatal, 
between  eleven  and  fourteen  days.  In  late  life  the  mortality  rate 
rises  again. 

The  sloughing  and  discharge  of  the  intussusceptum  must  be 
regarded  as  a  decidedly  favorable  circumstance,  since  of  408  chil- 
dren in  whom  the  sloughing  did  not  take  place  345  (i.  e.  85  per 
cent.)  died,  while  of  149  children  who  passed  the  sphacelated  por- 
tion of  gut,  61  (41  per  cent.)  recovered.  This  discharge  of  bowel 
occurs  very  rarely  in  early  infancy ;  it  is  most  common  wdieu  the 
ileum  is  involved  in  the  intussusception,  and  is  most  favorable  when 
it  is  observed  in  middle  life.  It  usually  occurs  between  the  eleventh 
and  twenty-first  day  of  the  attack. 

It  must  not  be  considered  that  after  discharge  of  a  sphace- 
lated bowel  the  danger  is  passed,  since  41  per  cent,  of  these  cases 
perish  at  any  time  between  a  few  hours  and  two  years  following 
the  acute  attack. 

In  case  there  is  no  sloughing  of  bowel,  the  colic  and  ileocecal 
invaginations  give  a  better  probability  of  life  than  do  those  of  the 
ileum. 

The  cause  of  death  is  usually,  in  children,  exhaustion  and  ina- 
nition. General  or  perforative  peritonitis  is  exceedingly  uncommon. 
In  the  adult,  perforation  and  resultant  peritonitis  are  of  frequent 
occurrence. 

Diagnosis. — The  diagnosis  of  intussusception  is  made  upon  the 
acute  onset  of  colicky  pain,  and  its  intermittent  character;  passages 
from  the  bowels  containing  blood  and  mucus  ;  the  presence  of  a 
tumor,  commonly  in  the  left  iliac  region,  or  felt  through  the  anus; 
varying  in  size  and  consistency  from  time  to  time,  with  an  erectile 


3G  WOUNDS    AND    OBSTRUCTION   OF    THE    INTESTINES. 

or  vermiform  motion  and  the  ordinary  obstruction  symptoms.  The 
diagnosis  is  further  confirmed  if  there  are  violent  peristalsis  and 
tenesmus,  and  if  these  symptoms  occur  in  an  infant. 

Treatment. — The  diagnosis  having  been  assured,  the  treatment 
will  be  either  medical  or  surgical.  And  even  in  those  hyper-acute 
cases,  where  death  takes  place  in  a  few  hours,  apparently  from 
shock,  the  first  resort  should  be  to  those  non-operative  means  to  be 
shortly  described,  and  which  have  many  times  proved  successful. 

The  pathology  of  the  disease  teaches  us  that  disin  vagi  nation 
becomes  more  difficult  in  direct  proportion  to  the  length  of  time 
which  has  elapsed  since  the  onset  of  symptoms ;  hence  every  hour 
diminishes  the  chances  of  success.  AVhatever  the  age  of  the  patient 
or  the  seat  of  the  trouble,  provided  the  case  is  not  of  such  long- 
standing that  tight  adhesions  have  probably  made  reduction  impos- 
sible, or  strangulation  has  produced  a  partial  necrosis,  ether  should 
be  administered  to  its  full  surgical  extent,  producing  complete 
relaxation  of  the  muscular  system ;  by  means  of  a  fountain  syringe 
hot  (105°  to  108°)  .7  per  cent,  saline  solution  should  be  slowly  (4 
ounces  to  the  minute)  forced  into  the  rectum  under  a  pressure  of 
not  over  two  pounds  to  the  inch  (elevation  of  the  irrigating  bag 
4  ft.),  the  liquid  being  retained  by  a  shoulder  upon  the  injection 
pipe,  readily  made  by  wrapping  it  with  a  narrow  bandage ;  the 
abdomen  should  be  thoroughly  kneaded,  the  manipulations  being 
so  planned  as  to  encourage  disinvagination.  This  treatment  should 
continue  for  thirty  to  forty  minutes,  the  pressure  being  gradually 
increased  by  raising  the  bag  till  a  pressure  of  not  over  eight  pounds 
is  produced,  and  may,  if  the  tumor  does  not  disappeai',  be  combined 
with  inversion  and  shaking. 

This  trial  at  forced  reduction  must  be  thorough  and  final ;  there 
should  be  no  idea  that  it  is  to  be  repeated  with  more  care  and  at- 
tention to  detail.  If  it  fails,  the  surgeon  must  proceed  to  an 
abdominal  section  for  the  purpose  of  accomplishing  disinvagination. 
If  there  is  a  distinct  tumor,  the  probable  success  of  the  method 
above  detailed  will  be  denoted  by  its  disappearance,  the  positive 
failure  by  the  tumor  occupying  the  same  position  as  before  treat- 
ment and  retaining  its  full  size ;  in  this  latter  case  the  surgeon  may 
proceed  to  operate  at  once  without  letting  the  patient  recover  from 
the  anaesthetic.     Where  there  is  anv  doubt  as  to  the  effect  of  the 


INTUSSUSCEPTION.  37 

treatment,  however,  and  this  will  be  in  the  majority  of  cases,  the 
patient  mnst  be  allowed  to  come  out  of  his  condition  of  anesthesia, 
when  the  progress  of  symptoms  will  quickly  decide  as  to  whether 
a  cure  has  or  has  not  been  effected. 

It  is  true  that  the  statistics  of  abdominal  section  for  invagina- 
tion appear  to  be  exceedingly  bad,  Ashhurst'  giving  the  mortality 
percentage  in  65  cases  at  75.4  per  cent.  There  can  be  but  little 
doubt  that  the  percentage  is  in  reality  even  higher  than  this,  since 
the  natural  tendency  is  to  report  favorable  cases.  Individual  ex- 
perience will  corroborate  this,  since  every  surgeon  can  recall 
unsuccessful  and  unreported  cases  of  which  he  has  personal  knoMd- 
edge  while  the  few  successful  cases  have  all  been  put  on  record. 

Heretofore  abdominal  section  has  been  considered  as  a  last  resort 
to  be  attempted  after  days  spent  in  repeated  and  ineflPectual  efforts 
at  reduction  by  small  enemata,  by  air  or  gas  insufflation,  by  in- 
version and  shaking,  by,  at  times,  full  doses  of  purgatives,  or 
pounds  of  metallic  mercury ;  when  the  patient's  strength  was  far 
spent,  and  inevitable  and  immediate  death  was  staring  him  in  the 
face. 

Under  these  circumstances  it  is  obviously  unfair  to  compare  the 
statistics  of  operative  cases  with  those  treated  expectantly,  yet  the 
mortality  against  the  surgeon  is  but  little  higher  (less  than  2  per 
cent.).  Given  an  equal  number  of  cases  treated  on  the  one  hand 
expectantly,  on  the  other  hand  by  immediate  operation,  it  would 
be  hard  to  find  an  abdominal  surgeon  who  doubts  but  that  his  per- 
centage of  success  would  justify  his  methods.  Considering  the 
class  of  cases  in  which  section  has  been  employed,  any  percentage 
of  success  would  be  encouraging;  if  resorted  to  when  all  condi- 
tions are  favorable,  that  is,  immediately  after  one  thorough  effort 
to  accomplish  reduction  without  operation,  we  believe  that  the  per- 
centage of  recovery  will  be  so  high  that  even  the  most  conservative 
will  be  disposed  to  recommend  it. 

While  it  is  granted  that  there  are  certain  cases  in  which  disin- 
vagination  cannot  be  effected,  and  in  which  nature  frequently  ac- 
complisiies  a  spontaneous  cure  by  sloughing,  it  must  be  remembered 
that  this  form  of  cure  is  very  rare  in  young  children,  and  that  over 
40   per  cent,  of  cases  thus  terminating  subsequently  perish  from 

1  Intei'iiat.  Encyc.  of  Surg.,  vol.  vi.,  p.  69. 


38  WOUNDS    AND    OBSTRUCTION    OF   THE    INTESTINES. 

the  direct  effects  of  the  inva<i'ination  and  foHowing-  necrosis.  In 
those  cases  where  the  severity  of  the  synn)tonis  and  tlie  amount  of 
obstruction  denote  much  strangulation,  and  whicli  have  not  been 
seen  for  several  days  from  the  onset  of  tlic  attack,  avc  believe  that 
section  should  be  the  first  resort. 

Abdominal  section  then  should  follow  immediately  upon  tlie 
failure  to  reduce.  The  incision  should  be  over  the  tumor  if  one  is 
demonstrable,  or,  in  the  absence  of  this  sign,  in  the  middle  line  of 
the  body,  below  the  umbilicus.  The  regions  of  preference  should 
be  searched,  and  the  invagination  being  found,  an  effort  at  reduc- 
tion should  be  made ;  not  by  pulling  upon  the  intussusceptum,  but 
by  grasping  the  tumor  at  its  loAvest  part,  and  by  gentle,  continued 
pressure,  reducing  the  venous  congestion ;  then  by  traction  from 
above  and  pressure  applied  from  below,  the  reduction  will  be  much 
facilitated.  If  adhesions  have  formed  about  the  neck,  a  probe 
passed  between  the  entering  and  returning  layer,  and  carried  around 
the  circumference  of  the  bowel,  may  enable  the  surgeon  to  break 
them  up,  and  thus  accomplish  reduction  which  would  otherwise  be 
impossible.  If  the  adhesions  are  so  tight  that  restoration  of  the 
gut  to  its  normal  condition  is  impossible,  we  believe  that,  unless 
the  patient's  strength  is  exceptionally  w^ell  preserved,  an  enteros- 
tomy and  formation  of  an  artificial  anus  will  afford  the  best  hope 
of  recovery,  since  it  has  been  shown'  that  even  where  the  cause  of 
obstruction  is  not  removed,  the  relief  afforded  by  this  operation 
frequently  enables  spontaneous  resolution  to  take  place  subsequently, 
with  complete  restoration  of  the  continuity  of  the  alimentary  canal. 
If  gangrene  has  set  in  and  is  involving  the  intussuscipiens,  resection 
with  the  formation  of  an  artificial  anus  to  be  subsequently  closed 
bv  plastic  operation ;  or,  in  exceptional  cases,  lateral  approximation 
will  be  indicated. 

Of  drugs,  but  two  should  be  used  in  invagination,  namely,  opium 
and  belladonna. 

In  another  part  of  this  paper  (see  Peritonitis)  is  discussed 
not  only  this  subject,  but  the  relative  merits  of  the  various  thera- 
peutic agencies,  mechanical  and  otherwise  (see  Treatment  of 
Obstruction),  commonly  employed  in  this  affection.  As  a  re- 
sult of  experimental  work,  of  practical  experience  in  this  class  of 

1  Curtis,  Med.  Rec,  Sept.  1,  1888. 


INTUSS  USCE  PTION. 


39 


cases,  of  careful  examination  of  elaborate  statistics,  we  are  con- 
vinced that  the  method  of  treatment  above  indicated  is  the  one 
which  will  give  the  most  satisfactory  results. 


INTUSSUSCEPTION. 


Total  number  of  cases 
Operative  cases 
Non-operative  cases 


(  Recovered 
t  Died 

.    11 

.      8 

1  Recovered 
es    < 

I  Died 

.   17 

,   32 

73 


Five  cases  results  not  given. 


CHAPTER  III. 

INTERNAL  STRANGULATION. 

As  a  cause  of  obstruction,  internal  strangulation  by  bands,  etc., 
ranks  in  order  of  frequency  next  to  intussusception,  contributing- 
more  than  25  per  cent,  to  these  cases,  or  according  to  our  own 
statistics  36  per  cent,  of  classified  cases.  It  occurs  most  frequently 
in  males  between  the  twentieth  and  fortieth  year,  and  is,  in  the 
great  majority  of  cases,  due  to  the  remains  of  a  former  peritonitis, 
thouo;h  strano-ulation  throuoh  the  foramen  of  Winslow,  through 
the  diaphragm,  and  into  congenital  or  acquired  peritoneal  diverti- 
cula, particularly  in  the  region  of  the  iliac  fossa  and  the  pelvns, 
have  been  many  times  observed.  In  regard  to  the  seat  of  internal 
strangulation  the  combined  statistics  of  Duchaussoy,  Besnier,  and 
Haven  give,  in  a  total  of  151  cases,  the  small  intestines  as  involved 
in  133,  and  our  own  figures  are  in  accord  with  this. 

Treves  classes  under  the  heading  "  Hernia-like  Strangulation  of 
the  Bowel  :"— 

1.  Isolated  peritoneal  adhesions,  due  to  former  peritonitis,  and 
the  subsequent  drawing  out  of  the  organized  lymph  by  means  of 
the  vermicular  motion  of  the  bowel  into  a  cord,  these  bauds  being 
generally  single  and  attached  by  their  two  extremities  to  practically 
any  portion  of  the  parietal  peritoneum  or  the  abdominal  viscera. 

When  a  short  band  stretches  tightly  over  a  firm  surface  the  gut 
may  slip  beneath  it  and  be  strangulated. 

When  there  is  a  long  band  not  very  tense,  and  attached  only  by 
its  extremities,  looping  or  knotting  may  occur.  Le  Bedois'  notes 
a  case  of  strangulation  by  a  band  passing  twice  around  a  loop  of 
the  ileum,  and  Leichtenstern  describes  a  mechanism  by  which  the 
false  ligament  being  sufficiently  loose  a  true  slip-knot  was  formed, 
in  the  loop  of  which  the  bowel  was  caught.  He  states  that  all 
these  knots  are  characterized  by  the  circumstance  that  the  moment 

I  Arch.  Gen.  de  M(?d.,  Par.  1827,  xiii.  230. 


INTERNAL   STE ANGULATION.  41 

the  gut  is  released  from  their  bight  they  can  immediately  be  drawn 
out  by  pulling  each  end. 

2.  Strangulation  hy  cords  foymed  from,  the  omentum. — Tnflannna- 
tory  adhesions,  due  either  to  traumatism  or  to  involvement  in 
peritonitis,  are  the  beginning  points  of  the  thick  strong  omental 
cords.  These  are  commonly  found  attaclied  about  the  region  of 
the  internal  inguinal  ring  of  the  left  side.  They  are  somewhat 
larger  and  looser  than  the  isolated  peritoneal  bands,  and  hence 
more  frequently  form  knots. 

3.  Strangulation  hy  Ifeekel's  diverticulum. — The  vitelline  pedicle 
attached  in  the  embryo  to  the  lower  fourth  of  the  iknim  sometimes 
persists,  and  may,  exceptionally,  exhibit  all  the  features  of  normal 
intestine.  Thus  Cruveilhier's^  operation  was  unsuccessful  because 
from  the  size  and  appearance  of  the  constricting  diverticulum  it 
was  taken  for  the  intestine.  More  commonly  it  is  represented  by 
a  blind  tube  or  fibrous  cord,  two  or  three  inches  in  length.  The 
extremity  of  the  diverticulum  may  be  attached  or  remain  free;  if 
attached  primarily,  it  will  be  found  at  or  just  below  the  position  of 
the  umbilicus.  This  attachment  may  be  ruptured  and  secondary 
adhesions  take  place  in  nearly  any  part  of  the  abdomen.  The 
diverticulum  is  found  to  be  much  more  common  in  the  male  than 
in  the  female. 

In  addition  to  the  true  Meckel  diverticulum  there  are  certain 
pouch-like  extensions  from  the  bowel,  sometimes  occurring  in  great 
numbers,  and  which  may,  by  contracting  adhesions  with  surround- 
ing parts,  or  with  each  other,  cause  strangulation  of  the  bowel.  It 
is  well  recognized  that  these  pouch-like  extensions  of  the  gut  are 
particularly  prone  to  take  place  into  the  substance  of  the  epiploic 
appendages  of  the  colon.  This  probably  was  the  condition  of  affairs 
in  a  case  reported  by  Holmes.^  The  bowel  was  strangulated  by  a 
ring  formed  by  two  adherent  appendices  epiploicse.  These  false 
diverticula  are  usually  rounded  or  saccular  in  shape,  and  are  subject 
to  inflammation  from  lodgment  of  undigested  food,  fruit-stones,  etc. 

4.  Strangidation  by  normal  structures  abnormally  attached;  and 
through  slits  and  apertures. 

In  the  first  caption  of  t-his  form  of  internal  strangulation  the 
vermiform  appendix  is  chiefly  at  fault.     It  sometimes  attains  the 

1  Gaz.  des  Hop.,  1872,  p.  102. 

2  Tr.  Path.  Soc,  Loud.  1860-61,  xii.,  iii. 


42  WOUNDS    AND   OBSTRUCTION    OF   THE    INTESTINES. 

length  of  six  or  eight  inehes,  and  may  contract  adhesions  at  some 
distance  from  its  normal  seat,  thns  producing  strangulation  of  a 
large  portion  of  the  bowel.  It  is  usually  adherent  to  structures 
lying  near  its  proper  position,  particularly  to  the  mesentery  of  the 
lower  portion  of  the  ileum. 

The  Fallopian  tube  is  at  times  the  constricting  agent.  Sedge- 
Avick^  repeats  a  case  of  this  nature. 

Strangulation  through  slits  and  rents  in  the  mesentery,  omentum, 
or  peritoneal  ligaments  has  been  often  noted.  Bailey^  reports  a 
case  where  three  feet  of  the  jejunum  Avere  strangulated  through  a 
rent  in  the  mesentery.  Diller^  describes  a  case  of  internal  hernia 
where  the  ileum  passed  through  a  rent  in  the  sigmoid  meso-colon. 
Deficiencies  in  the  broad  ligament  have  been  found  to  cause  stran- 
gulation. , 

The  cause  of  rents  in  the  mesentery  and  omentum  is  mainly 
traumatic,  though  a  congenital  origin  for  this  condition  cannot  be 
disproven.  Apertures  may  be  formed  by  the  loosening  of  the 
central  portion  of  broad  adhesions,  and  through  these  spaces  a 
portion  of  the  gut  may  pass  and  may  be  strangulated. 

Pathology. — Intestinal  strangulation  may  be  of  sudden  or  of 
gradual  development.  The  gut  may  be  violently  drawn  through  a 
small  aperture,  and  venous  congestion  and  complete  obstruction 
may  develop  at  once,  or  the  constriction  may  not  be  sufiicient  in 
itself  to  produce  marked  retardation  of  circulation  till  gaseous  dis- 
tention or  undigested  food  effects  an  increase  in  the  size  of  the 
imprisoned  loop  which  causes  venous  congestion,  after  which  the 
condition  rapidly  progresses  to  one  of  strangulation. 

As  in  the  case  of  hernia  the  vitality  of  the  bowel  is  sooner  or 
later  destroyed  by  the  blood  stasis,  mortification  takes  place,  first 
in  the  parts  most  remote  from  the  seat  of  constriction,  and  if  the 
patient  has  survived  the  first  onset  he  perishes  later  on  of  peritonitis, 
exhaustion,  or  septic  absorption.  The  average  duration  of  these 
cases  is  from  four  to  six  days. 

Symptoms  of  Internal  Strangulation. — The  acute  onset 
may  be  preceded  by  symptoms  of  colic  and  intestinal  indigestion. 

1  London  Lancet,  Feb.  11,  1888. 

2  Prov.  Med.  and  Surg.  Journ.,  Lond.  1852,  188. 

3  Mich.  Med.  News,  Detroit,  1881,  iv.  138. 


INTERNAL   STRANGULATION.  43 

Usually  without  cause,  and  where  the  patient  is  in  full  health, 
there  is — 

1.  Sudden  agonizing  pain,  constant,  and  located  about  the  um- 
bilicus, with  paroxysmal  increments. 

2.  A  rapid,  weak  pulse  and  suhnoi^mal  temperature. — This  is 
nearly  constant  in  the  early  stages  of  the  attack ;  later  on,  when 
local  or  general  peritonitis  develops,  the  temperature  and  pulse  may 
assume  the  features  characteristic  of  inflammation. 

3.  Vomiting. — First  of  the  contents  of  the  stomach,  then  of  bile, 
and  finally,  in  a  large  percentage  of  cases,  of  feculent  matter.  The 
fecal  vomiting  rarely  appears  before  the  third  day,  and  in  cases 
running  a  very  acute  course  death  may  ensue  before  this  symptom 
has  time  to  develop.  The  vomiting  is  constant  and  gives  no  relief 
to  the  patient. 

4.  Constipation. — Exceptionally  there  may  be  one  or  two  pas- 
sages representing  the  contents  of  the  bowel  below  the  seat  of 
obstruction  ;  after  that  the  constipation  is  absolute,  not  even  flatus 
passing  by  the  anus.  Treves  has  suggested  that  the  evacuations 
sometimes  observed  toward  the  termination  of  the  case  and  not  due 
to  the  relief  of  obstruction,  may  be  dependent  upon  the  beginning 
of  peritonitis. 

5.  Tympanitic  distention. — Where  there  is  a  large  segment  of  gut 
involved  in  the  strangulation,  its  early  distention  may  give  rise  to 
a  localized  abdominal  enlargement  which  is  exceedingly  suggestive 
as  to  the  cause  of  the  attack.  In  general  the  meteorism  is  not 
marked  except  when  peritonitis  supervenes. 

Since  in  the  large  majority  of  cases  the  obstruction  is  localized 
in  the  lower  portion  of  the  small  intestines,  the  primary  distention 
will  be  observed  in  the  mid-abdominal  region,  i.  e.,  the  epigastric, 
umbilical,  and  hypogastric  areas.  Laugier^  claims  by  this  symptom 
to  locate  the  obstruction  with  some  certainty. 

The  violent  peristalsis  and  repeated  vomiting  prevent  the  ex- 
treme meteorism  characteristic  of  intestinal  paralysis. 

6.  Localized  tenderness  and  percussion-dulness. — When  present 
these  signs  are  of  exceeding  great  importance,  since  they  denote  the 
position  of  the  strangulated  bowel. 

1  Bulletin  de  Chirurgie,  t.  i.  245. 


44  WOUXDS    AND    OBSTRUCTION    OF   THE    INTESTIXES. 

Exceptionally  a  tumor  may  be  felt  formed  by  the  congested  gut 
or  the  matting  together  of  the  intestinal  coils. 

The  urine  is  diminished  in  quantity  and  may  be  suppressed.  In 
acute  strangulation  it  commonly  contains  albumen  and  it  is  stated 
that  this  is  of  diagnostic  value. 

Diagnosis. — In  this  connection  the  history  is  of  great  imjjort- 
ance. 

Other  congenital  deformities  would  suggest  the  possibility  of 
Meckel's  diverticulum  as  a  cause. 

A  preceding  typhlitis,  pelvic  peritonitis,  or  severe  abdominal 
traumatism  would  respectively  assign  an  adherent  vermiform  ap- 
pendix, peritoneal  bands,  or  rents  in  the  omentum  or  mesentery  as 
the  causative  agents  in  the  production  of  the  symjjtoms. 

The  age  of  the  patient  should  also  be  considered,  since  this  form 
of  obstruction  usually  occurs  between  the  twentieth  and  fortieth 
year. 

The  sudden  onset  of  violent  persistent  pain,  subnormal  tempei'a- 
ture  and  frequent  pulse,  the  obstinate,  absolute  constipation,  the 
persistent,  repeated  vomiting,  becoming  fecal,  and  the  rapid  course 
of  the  disease,  all  point  to  internal  strangulation. 

Auscultation  of  the  abdomen  is  at  times  of  value,  a  sound  com- 
j)ared  to  the  click  of  the  water-hammer  being  heard  most  distinctly 
at  the  point  of  obstruction. 

Palpation  and  percussion  should  not  be  omitted,  as  thereby  the 
seat  of  obstruction  has  been  distinctly  located. 

Treatment, — Although  a  spontaneous  cure  of  internal  strangu- 
lation is  possible,  either  by  the  rupture  or  absorption  of  the  con- 
stricting band,  or  by  an  intestinal  anastomosis  by  ulceration,  this 
result  must  be  exceedingly  rare  when  the  condition  of  strangula- 
tion is  fully  established.  Nor  can  it  readily  be  conceived  in  what 
way  injections,  massage,  electricity,  or  any  or  all  of  the  therapeutic 
means  usually  resorted  to  in  cases  of  obstruction  can,  save  under 
exceptional  circumstances  and  then  by  the  merest  accident,  be  of 
the  slightest  avail.  Given  a  diagnosis,  and  in  any  case  of  obstruc- 
tion characterized  by  such  fulminant  symptoms  as  are  common  in 
strangulation,  abdominal  section,  Avith  the  idea  of  mechanically 
removing  the  cause  of  obstruction,  should  be  the  first  resort. 


INTERNAL   STRANCIULATION.  45 

The  contra-indication  to  immediate  operation  will  be  the  shock 
which  frequently  signals  the  onset  of  the  malady,  and  which  may 
result  fatally  in  a  few  hours.  This,  if  profound,  requires  treat- 
ment even  more  imperatively  than  the  "strangulation.  External 
heat,  full  doses  of  morphia,  atropia  and  ether  hypodermically,  and 
whiskey  by  the  bowel,  four  ounces  diluted  with  eight  times  that 
quantity  of  hot  water,  will  often  succeed  in  bringing  about  reaction. 

Even  should  the  condition  of  shock  not  be  benefited  by  these 
means,  if  the  symptoms  are  steadily  progressive,  the  surgeon  should 
not  hesitate  to  administer  the  minimum  amount  of  ether  necessary 
for  anaesthesia,  to  open  the  abdomen,  make  a  hurried  search  for 
the  seat  of  constriction  in  the  region  where  it  is  most  commonly 
found,  i.  e.,  lower  part  of  the  ileum,  perform  any  operation  for  its 
relief,  which  can  be  quickly  and  easily  executed,  and  flush  out  the 
peritoneal  cavity  with  hot  saline  solution  (108°  Fahr.). 

If,  urider  these  circumstances,  that  is,  operation  during  profound 
shock,  the  seat  of  obstruction  cannot  immediately  be  found,  or  if 
found,  the  constriction  is  of  such  a  nature  that  a  tedious  operation 
would  be  required  for  its  relief,  an  enterostomy  is  clearly  indicated, 
since  following  this  procedure  a  spontaneous  resohition  and  restora- 
tion of  the  normal  course  of  the  alimentary  canal  have  many  times 
taken  place. 

Where  the  patient  is  in  good  condition,  a  free  parietal  incision 
should  be  made,  followed  by  a  careful  systematic  search  for  the 
seat  of  the  obstruction ;  the  congestion  and  discoloration  of  the 
strangulated  bowel,  the  inflation  of  the  gut  above  the  point  of 
occlusion,  and  the  empty  flaccid  condition  of  the  intestine  below 
will  each  in  turn  guide  the  surgeon  to  the  seat  of  trouble.  Diver- 
ticula, if  large  and  patulous,  should  be  ligated  close  to  the  bowel, 
divided,  and  the  proximal  end  turned  into  the  lumen  of  the  latter 
by  a  Lembert  suture  applied  to  the  peritoneal  coat ;  the  remaining 
portion  of  the  diverticulum  should  be  completely  removed  lest  it 
give  rise  to  future  trouble.  Bands  from  either  parietal  peritoneum, 
mesentery,  or  omentum  should  be  ligated  as  near  their  points  of 
origin  as  possible  and  removed. 

Where  the  appendix  is  the  seat  of  trouble  its  ligation  and  com- 
plete removal  are  indicated,  followed  by  invagination  of  the  proximal 
end  and  final  closure  by  a  peritoneal  Lembert  suture.  When  the 
strangulation  is  caused  by  rents  or  apertures  in  either  the  mesen- 


46  WOUXDS    AXD    OBSTRUCTION    OF    THE    INTESTINES. 

tery,  omentum,  or  peritoneum  the  general  principles  governing  the 
treatment  of  external  hernia  should  prevail.  The  aperture  should 
be  enlarged  sufficiently  to  allow  of  easy  reduction,  and,  as  a  means 
of  preventing  recurrence  of  the  accident,  should  subsequently  be 
com2)letely  closed  by  suture. 

As  a  matter  of  prime  importance  the  distended  and  paralyzed 
bowel  should  be  evacuated  of  its  contents  by  means  of  one  or  luore 
incisions  which  can  be  closed  at  the  conclusion  of  the  operation. 

When  the  obstruction  is  due  to  the  matting  together  of  a  large 
mass  of  intestines,  unless  the  adhesions  are  readily  broken  down, 
the  safety  of  the  patient  will  be  consulted  best  by  performing  cither 
an  intestinal  anastomosis  between  the  healthy  bowel  leading  to  the 
adherent  coils  and  that  leading  from  it,  or  by  forming  an  artificial 
anus.  The  effect  of  time  and  of  the  constant  peristaltic  and  respi- 
ratory intra-abdominal  motions  is  often  marked  by  the  complete 
disappearance  of  most  extensive  intestinal  or  omental  adhesions. 

Beyond  the  treatment  of  shock  and  vital  depression,  the  adminis- 
tration of  alimentation  by  the  rectum,  the  free  use  of  stimulants, 
either  by  the  rectum  or  subcutaneously,  lavage  of  the  stomach,  and 
absolute  withholding  of  everything  by  the  mouth,  the  treatment  of 
these  cases  should  be  purely  surgical. 

After  the  cause  of  constriction  has  been  removed  a  saline  purge 
frequently  acts  most  happily  in  restoring  tone  to  the  paretic  bowel. 

INTERNAL   STRANGULATION. 

Total  number  of  cases      ........  83 

"          "         of  deaths   .........  78 

"          "         of  recoveries       .......  4 

One  case  not  stated. 

r  r\        ^-  S  Recovered     .     4 

I   Operative  \ 

I  Died     .         .  16 

Bands  64  -^  ,  o  jr. 

Non-operative     f  R'^co^ered      .     0 

I  IDied      .         .  44 

Apertures       10 


CHAPTER  IV. 

VOLVULUS. 

A^OLVULUS,  or  twisting  of  the  bowel,  occurs,  according  to  Brinton's 
statistics,  in  about  8  per  cent,  of  the  fatal  cases  of  intestinal  obstruc- 
tion. Treves  states  that  volvulus  forms  2.5  per  cent,  of  tliese  cases  ; 
our  own  statistics  give  a  result  of  4  per  cent.  The  twist  is  usually 
about  the  mesentery  as  an  axis ;  two  or  even  three  complete  turns 
are  found  at  times ;  exceptionally  the  gut  may  be  twisted  about  its 
own  axis.  Under  the  heading  of  volvulus  is  also  included  the 
knotting  together  of  different  portions  of  the  gut. 

This  form  of  intestinal  obstruction  occurs  usually  after  middle 
age,  and  is  much  more  commonly  observed  in  men  than  in  women. 
Of  18  cases  collected  by  Haven,  ^  16  were  men.^  The  portion  of 
the  bowel  most  frequently  aifected  is  the  sigmoid  flexure.  Even 
in  the  form  characterized  by  the  intertwining  of  several  loops,  it  is 
with  the  sigmoid  flexure  that  the  small  bowel  usually  becomes 
entangled. 

The  ascending  colon  and  c?ecum  and  the  small  intestines  may  be 
involved,  at  times,  in  this  condition. 

The  twisting  of  the  bowel  about  its  mesenteric  attachment  is, 
under  normal  conditions,  scarcely  possible.  Experimentally  we 
have  made  repeated  trials  to  produce  in  dogs  a  volvulus,  but  have 
always  failed,  the  bowel  quickly  returning  to  its  normal  j)osition. 

A  long  mesentery  with  a  comparatively  narrow  attachment  is 
necessary  for  the  development  of  the  twist.  This  may  be  congenital, 
more  commonly  it  is  acquired ;  years  of  constipation  so  dragging 
upon  the  sigmoid  flexure  that  it  is  enlarged,  the  two  extremities 
being  constantly  more  approximated,  until  the  condition  suitable 
to  the  development  of  the  trouble  obtains.  It  is  on  account  of  this 
slow  development  that  the  disease  is  commonly  observed  in  men 
past  middle  life. 

When  volvulus  appears  in  the  ascending  colon  and  csecum  it  is 

J  Amer.  Journ.  Med.  Sc,  Oct.  1855. 

2  In  oar  own  table  of  10  cases  64  were  for  men. 


48  WOUXDS    AXD    OBSTRUCTION    OF    THE    INTESTINES. 

commonly  dependent  upon  tlie  same  condition  as  in  the  case  of  the 
sigmoid  llexin'c,  /,  e.,  an  abnormally  elongated  mesentery.  There 
is  alsL)  in  this  position  a  peculiar  form  of  volvulus,  consisting  in  a 
twist  of  the  colon  about  its  longitudinal  axis,  which,  though  rare, 
has  been  clearly  described. 

When  the  small  intestine  is  aifected  by  volvulus  it  talces  the  form 
of  a  twist  upon  an  elongated  mesentery,  or  an  entanglement  between 
tw^o  or  more  intestinal  coils. 

Pathology. — Venous  congestion,  as  in  all  forms  of  intestinal 
obstruction,  plays  an  important  part  in  the  changes  dependent  upon 
volvulus.  The  involved  loop  becomes  shortly  engorged  with  blood, 
and  immensely  distended  from  decomposition  of  its  contents,  so 
that  even  when  mechanical  reduction  is  eifected,  unless  the  gas  be 
evacuated,  the  bowel  on  being  released  has  a  tendency  to  at  once 
assume  its  twisted  position.  Peritonitis  is  developed  very  constantly, 
and  if  the  congestion  is  not  relieved  the  constricted  portion  of  the 
bo^^'cl  becomes  gangrenous.  At  times  perforations  are  foi'med  above 
the  point  of  constriction,  but  this  is  rare.  All  the  intestines  become 
quickly  distended,  but  not  to  the  same  degree  as  the  volvulus ;  the 
latter,  in  fact,  frequently  becoming  so  immensely  inflated  as  to 
practically  fill  the  abdominal  cavity. 

Prognosis. — Treves  states  that  volvulus  in  the  sigmoid  flexure 
is  invariably  fatal  unless  relieved  by  surgical  interference,  and  the 
general  concensus  of  medical  opinion  is  to  the  hopelessness  of  medical 
treatment  when  this  part  of  the  bowel  is  involved.  Even  upon  the 
autopsy  table  Smith  found  that  he  could  not  undo  a  twist  of  the 
ca?cum  although  the  external  incision  extended  from  the  sternum 
to  the  pubes. 

There  is,  however,  clinical  evidence  as  to  the  possibility  of  reduc- 
tion when  the  small  intestine  is  involved  in  the  twist.  Thus  Kohle,* 
M'ho  had  treated  a  patient  by  oil  injection  for  obstruction,  found, 
upon  post-mortem  examination,  death  having  taken  place  from 
intestinal  paralysis,  clear  evidence  of  a  reduced  volvulus  at  the 
lower  part  of  the  ileum. 

In  the  chronic  form  of  volvulus  life  may  be  prolonged  for  months, 

1  Correspondez  Blatt  fiir  Scliu.  Aert  ,  July  15,  1889. 


voLvuLrs.  49 

or  even  years,  but  in  the  acut(!  forms  tlic  ])rog;nosis  must  be,  for 
cases  not  treated  surin;;i('ally,  abiiost  absolutely  bad.  Haven  states 
that  the  average  expectation  of  bfe  is  about  five  days. 

Symptoms. — Absolute  constipation,  vomiting,  which  gradually 
becomes  feculent,  and  abdominal  distention  are  present  in  volvulus 
as  in  other  forms  of  intestinal  obstruction.  According  to  the  seat 
and  nature  of  the  twist  symptoms  will  vary  somewhat,  being 
characterized  by  violence  of  onset  and  rapidity  of  course  in  pro- 
portion to  the  tightness  of  the  twist.  The  sigmoid  flexure  being 
the  commonest  seat  of  trouble,  the  symptoms  of  its  involvement 
are  usually  taken  as  a  type  of  this  displacement  in  general. 

A  history  of  const Ipatioii.-^ As  the  pathological  condition  neces- 
sary for  the  formation  of  the  twist  requires  a  long  period  for  its 
development,  there  is  commonly  a  history  of  previous  constipation. 
This  was  observed  in  70  per  cent,  of  Treves's  cases. 

Pain. — The  acute  onset  may  be  determined  by  a  long-continued 
constipation.  The  attack  is  usually  inaugurated  by  sudden,  severe, 
but  not  absolutely  agonizing  pain,  felt  about  the  umbilicus,  or  ex- 
ceptionally at  the  seat  of  trouble.  This  is  constant  with  exacerba- 
tions, but  gradually  diminishes.  It  is  accompanied  by  a  moderate 
degree  of  shock  or  nervous  prostration.  Shortly  following  the 
pain,  tenderness  is  manifest,  as  a  result  of  the  early  lighting  up 
of  local  peritonitis.  Treves  states  that  peritonitis  is  nearly  always 
quickly  developed,  in  connection  with  volvulus.  Haven's  tables, 
however,  show  that  this  complication  is  not  more  common  than  in 
internal  strangulation. 

Constipation. — This  is  one  of  the  most  constant  symptoms,  and 
in  all  of  Plaven's  cases  it  Mas  present.  It  is  usually  absolute.  In 
a  small  percentage  of  cases  it  has  been  preceded  by  diarrhoea. 

Very  frequently  tenesmus  is  a  prominent  feature. 

Vomiting. — This  is  much  less  constant  than  in  internal  strangu- 
lation and  is  usually  not  fecal.  It  is  frequently  slight  and  rarely 
repeated,  and  in  some  cases  is  altogether  absent. 

Meteorism. — This  symptom  is  usually  very  well  marked.  In- 
deed, it  is  in  this  form  of  intestinal  obstruction  that  the  abdominal 
distention  reaches  its  extreme  limit.  At  first  the  swelling  is  con- 
fined to  the  region  of  the  colon,  if  the  twist  is  in  its  usual  position. 
Later  the  small  intestine  is  involved,  as  peritonitis  destroys  its 
4  '  . 


50  WOUNDS   AND   OBSTRUCTION   OF  THE   INTESTINES. 

muscular  coutractility,  aud  stills  the  violent  peristalsis  provoked 
by  any  obstruction  to  the  onward  passage  of  the  intestinal  contents. 
This  tympanitic  distention  at  times  seriously  interferes  with  the 
respiratory  functions  and  may  be  the  immediate  cause  of  death. 

Following  the  condition  of  shock,  which  denotes  the  onset  of 
volvulus,  the  s^uiiptoms  of  a  sthenic  peritonitis  may  develop,  with 
the  wiry  pulse,  high  temperature,  and  excessive  tenderness  charac- 
teristic of  the  disorder ;  or  intestinal  paralysis,  great  distention,  and 
rapid  absorption  may  produce  a  condition  of  intestiuo-peritoneal 
septicaemia  from  which  the  patient  may  perish  with  no  other  symp- 
toms than  extensive  meteorism  aud  rapid  pulse.     (See  Peritonitis.) 

Diagnosis. — Old  age  is  generally  believed  to  predispose  to  vol- 
vulus, yet  Haven  gives  the  average  age  of  patients  sutfering  from 
this  form  of  obstruction  as  35 ;  our  own  tables  place  the  age  at  32. 

Sex  is  a  distinct  predisposing  factor,  the  large  majority  of  reported 
cases  having  been  men.  A  previous  history  of  constipation  is 
always  suggestive. 

If  then,  in  a  man  at,  or  past  middle  age,  of  constipated  habit, 
severe,  but  not  agonizing  pain  attended  with  symptoms  of  moder- 
ate shock  should  inaugurate  an  illness  characterized  by  moderate 
bilious  vomiting,  absolute  constipation,  and  great  abdominal  dis- 
tention, with  tenderness  on  pressure  appearing  shortly,  the  pro- 
bability of  volvulus  would  be  strong  and  would  be  still  further 
confirmed  were  tenesmus  present,  and  were  a  history  of  distention 
first  appearing  in  the  region  of  the  colon  given. 

Further,  by  means  of  water  injection  followed  by  abdominal 
palpation  and  percussion,  an  obstruction  of  the  bowel  between  the 
rectum  and  transverse  colon  can  be  readily  demonstrated. 

Treatment. — The  natural  tendency  of  these  cases  is  towards 
death.  Purgatives  are  as  evil  in  their  effects  as  in  other  forms  of 
obstruction,  and  their  administration  has  frequently  been  the  start- 
ing point  for  the  acute  outbreak. 

It  is  difficult  to  understand  how  enemata  could  be  of  service, 
since  the  bowel  is  very  early  fixed  by  distention,  by  congestion, 
and  by  peritonitis,  in  its  abnormal  position.  A  gradual  forced 
injection  of  water,  with  the  patient  in  the  knee  elbow,  or  inverted 
position,  might  possibly  be  productive  of  some  good. 


VOLVULUS.  ■  51 

We  think  there  is  but  one  treatment  for  these  cases,  and  tliat  is, 
immediate  operation  with  untwisting  of  the  bowel  segment  and 
evacuation  of  its  contents.  If  this  is  undertaken  l)eforc  distention 
lias  paralyzed  the  gut,  or  peritonitis  has  fixed  it  in  an  abnormal 
position,  the  prognosis  is  favorable. 

Lavage  of  the  stomach,  the  avoidance  of  food  by  the  mouth,  and 
in  general,  the  treatment  applicable  to  other  forms  of  obstruction 
are  valuable  here. 


CHAPTER  y. 

OBSTEUCTION  FEOM  POEEIGN  BODIES. 

Under  this  heading  are  conveniently  considered,  not  only  those 
cases  of  obstruction  due  to  foreign  bodies,  Avhich,  Avhen  swallowed, 
either  from  their  size,  or  from  a  peculiarity  in  conformation,  are 
capable  of  lodging  in  some  portion  of  the  alimentary  canal  and 
mechanically  blocking  the  onward  passage  of  its  contents,  but  also 
those  cases  in  which  acute  symptoms  are  produced  by  intestinal 
concretions,  enteroliths,  gall-stones,  hydatids,  or  any  mass  suffici- 
ently large  to  block  the  bowel, 

A  foreign  body  which  has  safely  passed  into  the  stomach,  if  of 
considerable  size,  is  liable  to  be  arrested  in  this  viscus. 

Should  it  pass  the  pylorus,  unless  there  be  congenital  or  acquired 
abnormality  in  the  lumen  of  the  bowel,  the  csecum  will  probably 
be  the  next  point  of  lodgement.  The  majority  of  foreign  bodies 
which  have  entered  the  bowel  and  not  been  discharged  by  the  anus 
are,  according  to  Caron,  found  in  the  ceecum. 

If  the  cpecum  is  passed,  discharge  is  not  yet  assured,  since  the 
rectum  is  also  a  favorite  lodging  phice  for  these  bodies. 

Substances  may  be  swallowed  which,  in  themselves,  are  not 
dangerous,  but  which  being  taken  in  large  numbers  or  great  quan- 
tity, may  form  a  conglomeration  which  can  effectually  occlude  the 
bowel.  Cherry-stones  very  frequently  produce  obstruction  in  tin's 
way.  Landais^  narrates  the  history  of  a  patient  who  passed  400 
of  these  stones  15  months  after  they  had  been  taken,  several  of 
them  showino-  sio;ns  of  beg-inniup;  veoetation. 

Cruveilhier^  reports  a  case  of  obstruction  due  to  a  mass  made  up 
of  617  cherry-stones.  Instances  are  noted  wdiere  concentric  masses 
of  hair  filling  the  stomach  and  small  intestines  caused  death.^ 

In  the  majority  of  cases  the  oesophagus  is  an  accurate  gauge  of 

1  Ancien.  Jour,  de  Med.,  xxxvii.,  p.  137. 

2  Anat.  Patli.,  livr.  26,  pi.  6. 

3  Aucieu.  Jour,  de  Med.,  1779,  t.  lii. 


OBSTRUCTION    PROM    FOREIGN    BODIES.  53 

the  possibility  of  a  body  passing  tiie  entire  length  of  the  alimentary 
canal,  the  chances  being  largely  in  favor  of  a  s])()ntaneoos  discharge 
of  whatever  has  passed  into  the  stomach  through  the  cardiac  valve. 
Charles  II.  of  England  (Bonet)  placed  a  razor  and  two  knives  in 
the  mouth  of  a  professional  sword  swallower;  they  were  s\vallowed, 
and  discharged  per  annm  on  the  third  day.  On  the  antliority  of 
Longius  it  is  stated  that  a  sharp  pair  of  scissors  swallowed  by  an 
epileptic  were  evacuated  on  the  9th  day.  Bonchet'  quotes  Gosse- 
lin's  observation  of  a  sailor,  who  having  swallowed  a  pipe  suffered 
for  ten  days  with  colic,  nausea,  and  vomiting,  when  a  natural  dis- 
charge of  the  offending  body  produced  instant  relief.  The  pipe 
could  be  felt  through  the  abdominal  walls  and  its  progress  from 
day  to  day  distinctly  outlined. 

In  contrast  with  these  cases  Denovilliers  notes  an  autopsy  which 
showed  that  death  had  resulted  from  the  obstruction  caused  by  a 
single  cherry-stone  occluding  a  strictured  part  of  the  gut. 

The  foreign  bodies  may  be : — 

1.  Large,  but  regular  or  rounded  in  outline.  Here  there  is 
every  prospect  of  spontaneous  discharge  without  damage  to  the 
intestine ;  coins,  marbles,  pebbles,  etc.,  would  be  classed  under  this 
category. 

2.  Large,  irregular  and  angular  in  outline ;  edged  or  pointed. 
Although  the  probability  is,  even  in  these  cases,  that  spontaneous 
discharge  will  take  place,  serious  complications  are  likely  to  arise. 
Injury  to  the  mucous  membrane  of  the  bowel,  perforation  of  all 
its  coats,  lodgement  and  blocking  of  its  lumen  may  occur.  False 
teeth,  knives,  spoons,  scissors,  nails,  etc.,  are  classed  under  this 
heading. 

3.  Small  in  size,  of  regular  shape,  single  or  numerous.  A  single 
body  of  this  nature  can  only  by  the  rarest  exception,  as  in  the  case 
cited  above,  produce  obstructive  symptoms.  Masses  of  such  bodies 
are  the  commonest  cause  of  the  form  of  obstruction  under  consid- 
eration. Cherry-stones,  date-stones,  prune-stones,  grape-seeds  are 
the  representatives  of  this  class  of  foreign  bodies. 

4.  Small  in  size,  sharp  or  pointed,  single  or  numerous.  Here 
the  danger  to  life  is  slight.  Perforation  and  migration  of  the  for- 
eign bodies  frequently  takes  place  but  rarely  causes  serious  symp- 

1  Bull,  de  la  Soc.  Anat.,  30,  1855. 


54  1V0UNDS   AND   OBSTRUCTION   OF   THE    INTESTINES. 

toms.  "When  large  numbers  of  such  bodies  are  taken,  masses  are 
formed  which  may  produce  obstruction  or  perforative  peritonitis. 
Pins  and  needles,  which  have  been  swallowed  by  the  pound  with- 
out causing  death/  represent  this  class. 

Gall-stones. — Under  the  heading  of  large  bodies  of  rounded 
outline  would  fall  gall-stones.  Obstructive  symptoms  from  this 
cause  are  rare,  since  an  enormous  size  must  be  reached  before  the 
bowel  becomes  unable  to  expel  the  ojbstructing  mass.  When  lodge- 
ment is  once  effected,  the  stone  may  remain  for  months  in  one  posi- 
tion, giving  rise  to  no  characteristic  symptoms  and  steadily  enlarg- 
ing by  a  surface  deposit  of  earthy  matter.  Leichtenstern  states 
that  one  such  stone  was  ujjwards  of  five  inches  in  circumference. 
The  common  lodging  places  were  in  order  of  frequency,  in  Leich- 
tenstern's  thirty-two  cases,  the  lower  part  of  the  ileum,  the  duode- 
num and  jejunum,  and  the  middle  of  the  ileum.  This  form  of 
occlusion  occurs  most  frequently  in  females  and  after  middle  age 
has  been  passed. 

Enteroliths  are  practically  foreign  bodies  in  the  bowel,  and 
act  simply  by  their  large  size.  Leichtenstern  describes  one  which 
was  nine  inches  in  circumference.  Tliey  are  usually  formed  about 
a  foreign  body,  as  a  cherry-stone,  or  piece  of  vegetable  fibre.  They 
may  be  mainly  phosphatic,  in  that  case  being  arranged  in  concen- 
tric layers  and  being  distinctly  calculous  in  weight  and  consistency. 
They  may  be  made  up  of  mineral  matter  swallowed  in  the  form 
of  medicine,  particularly  of  magnesia,  or  they  may  be  formed  of 
vegetable  or  animal  matter  densely  packed  together  and  inter- 
mingled and  encrusted  with  a  certain  amount  of  lime  salts.  They 
are  usually  found  lodged  in  the  caecum. 

They  are  most  frequent  in  men  before,  or  about  the  period  of 
middle  age,  and  very  exceptionally  cause  obstructive  symptoms. 
(.2  per  cent.) 

Pathology. — The  lesions  produced  by  foreign  bodies  are  ; — 

1.  Ulceration,  with  or  without  subsequent  cicatrization  and  stric- 
ture of  the  bowel. 

2.  Perforation,  with  or  without  either  general  peritonitis  or 
parietal  abscess  formation. 

1  Bull,  de  la  Soc.  Anat.,  17  an.  p.  274. 


OBSTRUCTION   PROM   FOREIGN   BODIES.  55 

3.  Acute  or  chronic  obstruction  with  tlie  resultant  jialliologif-al 
changes  in  the  gut. 

LeDentu^  reports  a  case  in  which  a  wooden  kitchen  spoon  per- 
forated the  stomach  within  fifteen  hours  of  its  entrance  into  that 
organ,  and  passing  between  the  two  anterior  layers  of  the  omentum 
entered  the  general  peritoneal  cavity  without  producing  symptoms 
of  peritonitis. 

Prognosis. — This  is  usually  favorable;  considering  the  immense 
number  of  foreign  bodies  swallowed  it  is  certainly  the  rare  excep- 
tion in  which  obstructive  symptoms  are  subsequently  developed. 

Symptoms. — In  addition  to  the  history  of  a  foreign  body  having 
been  swallowed,  of  attacks  of  hepatic  colic,  or,  where  a  gall-stone 
ulcerates  through  into  the  bowel,  of  some  local  peritonitis  about 
the  region  of  tlie  liver,  there  can  commonly  be  elicited  a  record  of 
sharp  colicky  pains,  of  partial  obstruction,  and  of  vomiting.  The 
distention  is  slight,  the  amount  of  sj'stemic  shock  far  less  than  in 
other  forms  of  obstruction,  and  the  duration  of  the  attack  some- 
what longer  than  usually  obtains  in  this  class  of  affections.  The 
symptoms  of  obstruction  are  freqently  only  partial,  the  vomiting 
being  moderate  in  amount  and  not  stercoraceous,  the  constipation 
not  being  absolute. 

Except  in  the  case  of  enteroliths  and  very  large  foreign  bodies  a 
tumor  can  rarely  be  felt. 

Diagnosis. — It  is  often  impossible  to  diagnose  this  form  of 
obstruction  from  that  depending  upon  a  narrowing  of  the  lumen 
of  the  bowel,  such  as  cancer  or  stricture  produces.  The  previous 
history  is  always  of  great  importance.  The  presence  of  indican 
rather  than  albumin  in  the  urine,  the  comparative  mildness  of  the 
attack,  the  moderate  meteorism,  and  the  slower  course  of  the  dis- 
ease, all  help  to  exclude  internal  strangulation  or  volvulus.  It  is, 
however,  mainly  upon  the  history  that  the  diagnosis  will  be  founded.' 

Treatment. — Where  obstruction  is  fully  developed  and  the 
diagnosis  of  foreign  body  in  the  causative  role  clearly  established, 

1  La  Semaine  med.,  Jan.  9tli,  1889. 


56  WOUNDS   AND    OBSTRUCTION    OF    THE    INTESTINES. 

an  alxlominal  section,  enterotomy  and  removal,  Avitli  snbseqnent 
enterorraphy  with  Lcmbort  siitnres  is  indicated.  If  the  lodgement 
is  in  the  rectnm  the  body  shonld,  of  conrse,  be  removed  through 
the  bowel.  Radestock'  performed  enterotomy  twice  and  gastrotomy 
once  upon  the  same  patient  to  remove  many  foreign  bodies  swal- 
lowed with  suicidal  intent.  If  operation  be  absolutely  refused,  the 
controlling  of  pain  and  violent  peristalsis  by  morphia  hypodermi- 
cally,  deep  forced  enemata,  gentle  massage,  and  feeding  by  the 
rectum  may  be  tried.  After  acute  obstructive  symptoms  have 
passed  off,  a  continued  gentle  action  upon  the  bowels  by  means  of  a 
pill  composed  of  aloin,  strychnia,  and  belladonna  has  been  exceed- 
ingly satisfactory  in  its  results. 

1  New  Orleans  Med.  and  Surg.  Jour.,  Sept.  1889. 


CHAPTER  YI. 

INTESTII^AL   PARALYSIS. 

Certaijst  cases  of  intestinal  obstruction  occur  and  frequently 
run  on  to  a  fatal  issue,  yet,  at  the  autopsy  no  sufficient  cause  can 
be  found  for  the  symptoms  observed  during  life.  These  cases  are 
classed  by  Henrot  under  the  name  Pseudo-strangulation,  and  are 
classified  as  follows  : — 

1.  Cases  dependent  upon  paralysis  of  the  muscular  coat  of  the 

bowel,  due  to  pathological  changes. 

2.  Cases  in  which  the  muscular  coat  is  intact,  the  symptoms 

depending  upon  reflex  action. 

3.  Cases  in  which  there  is  paresis  or  paralysis  dependent  uj^on 

a  general  condition  of  the  nervous  system. 

The  symptoms  dependent  upon  conditions  under  Henrot's  second 
and  third  heading  are  usually  evanescent  in  character  and  threaten 
danger  to  life  or  cause  difficulty  in  diagnosis  only  for  a  very  brief 
period.  Inflammation  of  the  abdominal  parietes,  severe  injury  to 
the  testicle,  operations  about  the  rectum,  or  general  hysteria  have 
all  been  accompanied  by  symptoms  of  acute  intestinal  obstruction 
wdiich  were  promptly  relieved  by  attention  to  the  condition  which 
had  excited  the  reflex. 

After  abdominal  wounds,  however,  tedious  laparotomies,  or 
severe  contusions  in  the  abdominal  region,  there  may  be  developed 
a  condition  of  intestinal  paralysis  which  quickly  leads  to  obstruc- 
tion, to  great  distention,  and  to  death  from  either  septic  absorp- 
tion, exhaustion,  or  peritonitis;  it  is  to  this  condition  far  more  than 
to  well-developed  inflammation  that  the  ovariotomist  of  the  past 
can  trace  many  of  the  deaths  following  operation.  We  have  fre- 
quently examined  post  mortem  the  abdominal  cavities  of  these  cases, 
perishing  a  few  days  after  operation  and  presenting  the  charac- 
teristic symptoms  of  obstruction,  and  have  found  nothing  beyond 
enormous  distention  of  the  gut  with  kinking,  moderate  injection, 
and  a  slight  sero-sanguinolent  effusion. 


58  MOUXDS   AND    OB8TRUCTIOX    OF   THE    INTESTINES. 

It  is  probable  that  in  all  of  these  cases,  or  at  least  the  great 
majority,  the  symptoms  are  dependent  upon  extension  of  irritation 
or  inflammation  from  the  mucous  or  peritoneal  coat  of  the  bowel 
rather  than  upon  pure  reflexes. 

A  certain  number  originate  from  au  attack  of  acute  indigestion, 
and  as  a  typical  example  of  this  can  be  cited  Henrot's  XXI.  obser- 
vation, which  that  author  takes  as  an  example  of  pure  paralysis. 
A  man  of  66  years'  was  seized  with  colic,  cramps,  and  bilious 
vomiting,  great  distention  and  absolute  constipation  followed  with 
a  fatal  termination  on  the  fifth  day.  Absolutely  no  obstacle  to  the 
passage  of  the  intestinal  contents  w^as  found  at  the  autopsy. 

Inflammation  or  ulceration  of  the  mucous  membrane  not  rarely 
causes  cessation  of  peristalsis  and  resultant  obstruction  symptoms. 
Thus  Denarie  recounts  the  history  of  a  man  of  66  who  died  after 
nearly  two  weeks  of  absolute  constipation,  there  was  great  mete- 
orism  and  consequent  systemic  depression,  but  no  pain  or  fever. 
At  the  autopsy  a  recent  ulcer  of  the  descending  colon  was  found, 
beyond  this,  nothing  pathological  in  connection  with  the  intestinal 
canal  except  great  distention. 

Long-continued  venous  congestion  may  be  followed  by  absolute 
paralysis  of  the  muscular  coat  of  the  bowel.  The  literature  of 
hernia  is  full  of  records  where,  after  reduction,  symptoms  have  not 
abated  and  death  has  ensued  as  inevitably  as  though  the  gut  were 
still  strangulated. 

Severe  abdominal  traumatism  is  frequently  followed  by  imme- 
diate meteorism  with  obstructive  symptoms.  Three  cases  of  this 
nature  have  fallen  under  our  personal  observation,  one  progressing 
to  a  fatal  issue.  In  the  last  the  absence  of  internal  gross  lesion 
could  not  be  confirmed,  as  an  autopsy  was  refused. 

Jordan^  believes  that  fatty  degeneration  of  the  muscular  coat  of 
the  bowel  may  act  as  a  direct  and  indirect  cause  of  intestinal 
obstruction  and  death.  In  one  case  the  microscope  confirmed  the 
fatty  change  which  the  muscular  fibres  were  supposed  to  have 
undergone.  The  patients  who  exhibit  this  degeneration  are  those 
who  suffer  from  fatty  changes  in  other  parts  of  the  body.  The 
ultimate  paralysis  is  commonly  produced  by  flatulent  distention, 
but  any  injury  or  operation  about  the  peritoneal  cavity  or  pelvis 

1  Brit.  Med.  Jour.,  April  26,  1879. 


INTESTINAL   PARALYSIS.  59 

may  determine  the  incompetency  of  tlic  already  weakened  muscnlar 
fibres,  the  patient  perisliing  with  obstructive  symptoms,  tympany 
being  well  developed.  The  anxiety  which  all  la])arotomists  feel  in 
operations  upon  excessively  fat  patients  is  not  because  of  the 
mechanical  difficulties  which  the  thick  abdominal  walls  and  loaded 
omentum  offer,  but  because  it  is  universally  recognized  that  in  these 
patients  symptoms  of  obstruction  are  peculiarly  prone  to  occur. 

Jurgens^  describes  a  pathological  change  affecting  not  only  the 
muscles  of  the  bowel  but  also  the  terminal  nerve  filaments.  Henrot^ 
notes  the  invasion  of  the  muscularis  by  certain  sclerosed  areas. 
Nepva  detected,  in  a  case  of  fecal  obstruction,  atrophy  of  the 
muscular  coat  of  the  bowel.  Thibierge^  found  in  the  bowel  of  the 
aged  suffering  from  obstinate  constipation  glandular  atrophy,  wast- 
ing of  the  muscular  coat  and  probably  of  the  intra-parietal  nerves, 
and  arterial  atheroma.     Intestinal  paralysis  may  result  then — 

1.  From  a  general  neurotic  or  hysterical  condition. 

2.  From  local  reflex  action. 

.3.  From  abdominal  traumatism,  or  exposure  of  the  abdominal 
viscera. 

4.  From  enteritis  or  peritonitis. 

5.  From  atrophy  or  fatty  degeneration  of  the  muscular  coat  of 
the  bowel. 

The  form  of  paralysis  associated  with  distention  and  septic 
absorption  will  be  considered  later. 

Prognosis.— This,  if  the  case  is  recognized  early  and  the  general 
condition  is  not  too  profoundly  depressed,  is,  except  in  post-opera- 
tive cases,  less  serious  than  is  the  case  with  any  other  form  of  acute 
obstruction.  Since,  without  the  corroborative  testimony  of  an 
autopsy,  it  is  impossible  to  say  whether  or  not  obstruction  has 
depended  upon  paralysis,  statistics  upon  this  subject  cannot  be 
given.  There  is  good  reason  for  believing,  however,  that  many  if 
not  the  majority  of  cases  of  internal  strangulation,  volvulus,  etc., 
cured  by  such  remedial  means  as  puncture,  salines,  enemeta,  and 
massage  have  in  reality  been  cases  of  paretic  obstruction,  since  it 
is  difficult  to  conceive  how  these  measures  could  be  of  the  slightest 
use  were  the  conditions  diagnosed  actually  present. 

1  Berlin.  Klin.  Wooh.,  1881.  2  Union,  med.,  1878. 

3  Thes.  de  Par.,  1884,  No.  231. 


60  WOUXDS    AXD    OBSTRUCTION    OF    THE    INTESTINES. 

Symptoms. — A  jnirely  neurotic  jmriilytic  ohstriu'tion  would 
probably  be  marked  by  irregularity  in  eoui'^e,  and  the  character- 
istic manifestations  of  disordered  nerve  action.  AVhen  observed 
it  has  been  in  the  person  of  younii'  hysterical  females. 

The  reflex  paralysis  has  also  been  characterized  by  a  compara- 
tively short  diu'ation  and  sudden  disappearance  of  symptoms  on 
attacking-  the  source  of  the  nervous  disturbance. 

The  paralysis  dependent  upon  abdominal  injury  or  visceral  ex- 
posure is  that  most  commonly  met,  since  it  is  this  form  Avhich  occurs 
after  operations.  Any  degeneration  of  the  intestinal  walls  strongly 
predisposes  to  the  development  of  this  form  of  obstruction,  though 
it  may  appear  when  the  gut  is  perfectly  healthy.  Many  authors 
have  lately  called  attention  to  this  condition,  until  recently  con- 
founded with  peritonitis.  Thus  Malcolm^  shows  that  intestinal 
paralysis  is  an  important  factor  to  be  considered  in  the  after- 
treatment  of  abdominal  section.  Olhausen^  describes  paralysis  of 
the  intestines,  or  pseudo-ileus,  as  a  hitherto  unrecognized  cause  of 
death  after  laparotomy,  and  Verchere,  under  the  heading  "  Intestino- 
peritoneal-septicsemia"  (see  section  on  Peritonitis),  justly  describes 
death  in  these  cases  to  the  intestinal  palsy. 

The  characteristics  of  this  condition,  as  usually  observed,  are  as 
follows  :  After  a  prolonged  operation  with  possibly  partial  eventra- 
tion, or  much  exposure  of  the  intestines,  the  course  of  the  patient 
may  seem  satisfactory  for  one  to  three  days,  when  a  condition  of 
partial  collapse  is  developed.  This  is  usually  gradual  in  onset, 
but  may,  unless  the  patient  is  carefully  watched,  seem  sudden  in 
development.  The  pulse  is  rapid  and  running,  the  belly  quickly 
becomes  greatly  distended,  there  is  vomiting  either  of  ingested 
food  or  bilious  matter,  and  finally  there  is  absolute  constipation. 
Pain  may  at  first  be  exceedingly  severe  but  does  not  reach  the 
agonizing  intensity  characteristic  of  strangulation. 

There  is  no  marked  tenderness  and  no  characteristic  alteration  in 
the  temperature.     Death  seems  to  occur  from  heart  failure. 

Olhausen  states  that  a  venous  hypera?mia,  consequent  u})on 
mechanical  disturbance,  is  the  cause  of  the  trouble,  and  that  it  does 
not  immediately  develop  is  probably  due  to  the  fact  that  a  certain 
amount  of  time  is  required  for  fermentation  of  the  contents  of  the 


1  Med.-Chirur.  Trans.,  vol.  xxi. 

2  Ceiitralbl.  fur  Gyu.,  1888,  p.  10. 


INTESTINAIi   PARALYSIS.  61 

gut,  when  gaseous  distention  completes  the  paralysis  of  the  par- 
tially cri])])lcd  bowel,  and  adds  to  tlic  im])er]neal)ility  of  the  canal 
by  the  kinking  which  great  inflation  generally  prcxliices. 

The  symptoms  of  paralytic  obstruction,  depending  upon  degen- 
erative changes  of  the  muscular  layer  of  the  bowc.'l,  arc  fairly 
characteristic.  The  patients  are  usually  advanced  in  years,  and 
not  rarely  show  atheromatous  or  fatty  change  in  other  ])arts  of  the 
body.  There  is  a  preceding  history  of  long-contined  constipation, 
and  possibly  of  occasional  attacks  of  temporary  obstruction.  The 
acute  onset  is  usually  preceded  by  an  unusually  long  and  olistinate 
constipation,  symptoms  of  obstruction  develdj)ing  after  the  taking 
of  an  active  purge. 

Pain  at  times  denotes  the  beginning  of  acute  symptoms ;  this 
may  be  so  intense  as  to  suggest  internal  strangulation.  Thibierge 
states  that  this  pain  is  due  to  the  mechanical  eiFect  of  stretching 
upon  the  intra-parietal  bowel  nerves.  Often  pain  is  not  a  con- 
spicuous feature  of  the  attack. 

Distention  is  well  marked  and  involves  the  whole  abdomen.  At 
times  in  the  c?ecum  and  sigmoid  flexure  the  presence  of  fecal  ac- 
cumulations may  be  perceived  by  palpation  and  percussion. 

Vomiting  is  usually  well  marked ;  it  may  become  bilious,  but 
not  fecal.     At  times  it  is  entirely  absent. 

Constipation  is  from  the  beginning  of  acute  symptoms  absolute. 

Tenderness  is  usually  absent — the  temperature  remains  about 
normal,  the  pulse  steadily  increases  in  rajyldity  and  the  patient 
perishes  of  exhaustion  or  septic  absorption. 

Treatment. — In  this  condition  death  seems  to  be  produced  by — 

1.  The  mechanical  interference  to  respiration  occasioned  by  the 
enormous  distention. 

2.  The  exhaustion,  consequent  upon  the  cessation  of  assimilation, 
the  pain,  and  the  constant  vomiting. 

3.  Septic  absorption. 

It  is  particularly  in  this  class  of  eases  that  salines  have  won  their 
reputation.  Administered  in  the  first  stage  before  paralysis  is 
fairly  developed  they  seem  to  have  the  power  of  re-establishing 
peristalsis,  of  restoring  tone  to  the  muscular  coat  of  the  bowel  and 
of  sweeping  from  the  intestine  the  partially  digested  matter  ripe 
for  fermentation  and  putrefaction.     That  the  paralysis  dependent 


62  WOUNDS   AND   OBSTRUCTION   OF   THE   INTESTINES. 

upon  a  beginning  typhilitis,  salpingitis  or  any  form  of  local  peri-' 
tonitis  has  been  many  times  avoided  by  the  prompt  administration 
of  saline  cathartics,  cannot,  for  a  moment,  be  doubted.  Salines, 
then,  should  be  administered  freely  in  the  beginning  of  this  form 
of  obstruction. 

If  distention  has  reached  any  great  development,  and  vomiting 
has  set  in,  salines  are  no  longer  indicated.  Absolutely  nothing 
should  be  given  by  the  mouth,  lavage  of  the  stomach  should  be 
practised,  the  rectal  tube  should  be  inserted  to  excite  peristalsis  of 
the  colon  and  draw  oif  the  wind  in  the  rectum,  the  patient  should 
be  freely  stimulated  by  whiskey,  per  rectum  or  hypodermically,  and 
the  faradic  current  should  be  applied  with  one  metal  pole  within 
the  anus,  the  other  swept  over  the  motor  points  of  the  abdominal 
muscles. 

If  the  distention  still  increases,  repeated  punctures  into  the  in- 
flated intestinal  loops  may  be  made  with  an  aspirator  or  hypodermic 
needle.  Finally,  if  death  threatens  from  septic  absorption,  the 
abdomen  should  be  opened,  the  bowel  incised  in  as  many  places  as 
evacuation  of  its  gaseous  and  liquid  contents  requires,  and  an  arti- 
ficial anus  should  be  formed  in  the  full  confidence  that  should  the 
patient  recover  from  the  acute  attack,  spontaneous  closure  will 
probably  take  place. 

The  over-distention  being  relieved,  there  is  a  chance  that  the 
tonus  of  the  muscles  may  be  restored.  For  spontaneous  resolu- 
tion when  the  meteorism  reaches  an  extreme  limit  there  is  not  the 
slightest  hope. 

Where  there  is  acute  pain  morphia,  administered  hypodermically, 
is  of  great  service ;  except  for  belladonna  and  strychnine,  pushed 
to  their  extreme  physiological  limit,  there  is  little  indication  for  the 
use  of  other  drugs. 


CHAPTER  VII. 

CHRONIC   OBSTRUCTION. 

Spasmodic  Obstruction. — In  the  writings  of  tliirty  years  ago 
frequent  references  were  made  to  spasmodic  ilens,  and  the  belief  in 
this  form  of  obstruction  was  commonly  accepted.  With  the 
growth  of  pathological  knowledge,  however,  a  certain  amount  of 
skepticism  has  developed,  till  in  the  present  day  the  majority  of 
text-books  dealing  with  intestinal  troubles  make  no  mention  of  the 
possibility  of  spasm  causing  occlusion  of  the  bowel.  There  can  be 
little  doubt  that  in  cases  of  stricture  or  other  forms  of  narrowing 
of  the  intestinal  lumen,  there  is  frequently  a  spasmodic  element 
which  determines  the  onset  of  an  acute  attack  of  obstruction. 
Though  it  is  hard  to  disprove  that  muscular  contraction,  pure  and 
simple,  is  able  to  produce  the  symptoms  characteristic  of  ileus, 
there  is  certainly  no  pathological  evidence  to  prove  that  this  has 
occurred.  Both  Jacoud^  and  Cherchewski,^  however,  state  that 
they  have  observed  this  form  of  obstruction,  particularly  in  hys- 
terical and  neurotic  patients. 

Certain  rare  forms  of  obstruction,  the  diagnosis  of  which  is  not 
possible  during  life,  are  occasionally  observed.  Thus  in  the  South 
African  Medical  Journal  (November  30,  'S9),  is  reported  a  case 
which,  on  post-morten  examination,  was  found  to  present  an 
appearance  as  though  six  inches  of  the  jejunum  were  gangrenous. 
On  careful  examination  this  was  found  to  be  a  thrombus,  lying 
between  the  peritoneal  and  muscular  coats  of  the  bowel,  and  so 
large  that  the  lumen  of  the  latter  was  completely  occluded. 

Several  instances  of  embolism  of  the  superior  mesenteric  artery, 
with  resultant  mortification  of  a  portion  of  the  intestine,  are  on 
record. 

Chronic  Obstruction. — This  form  of  obstruction  is  produced 
by  any  cause  which  gradually  engenders  a  narrowing  of  the  bowel 

1  Path.  int.  t.  II.  2  Rev.  de  Med.,  1883. 


G4  AVOUXDS    AND    OBSTRUCTION    OF    THE    INTESTINES. 

lumen.  Thus  the  shriukiug  of  plastic  lyuipli  deposited  upon  the 
bowel  surface  during  an  acute  inflammation ;  the  cicatricial  con- 
traction following  ulceration,  whether  simple,  tubercular,  tvplioid, 
or  syphilitic ;  the  narrowing  following  the  extrusion  by  sloughing 
of  an  intussusceptum ;  the  gradual  blocking  caused  by  matting 
together  of  coils  of  the  bowel  by  extensive  adhesions,  by  the 
dragging  upon  }.\n  appendix  of  by  kinking  in  connection  with 
adliesions;  and 'finally  the  encroachment  upon  the  lumen  of  the 
bowel  by  new  growths,  all  ])roduce  the  symptoms  of  chronic 
obstruction.  In  addition,  any  of  the  conditions  considered  under 
the  head  of  acute  obstruction  may,  if  there  is  not  immediate  and 
complete  occlusion  of  the  bowel,  pass  into  the  chronic  form  of  the 
disorder. 

In  the  case  of  stricture  the  bowel  above  the  point  of  narrowing 
is  commonly  dilated  and  ulcerated.  The  amount  of  narrowing  is 
not  necessarily  indicated  by  the  severity  of  symptoms,  since  fre- 
quently deatli  occurs  with  an  opening  so  large  that  it  is  hard  to 
imagine  why  the  obstruction  could  not  be  relieved. 

The  most  characteristic  symptoms  of  chronic  obstruction  are  as 
follows  :  irregular  attacks  of  colicky  pain,  increasing  in  frequency 
and  appearing  a  few  hours  after  eating.  There  is  frequently  vomit- 
ing, which  may  become  fecal  on  the  supervention  of  an  acute  attack, 
it  is  rarely  copious.  There  is  not  often  much  meteorism,  and  peris- 
talsis can  frequently  be  seen  plainly  through  the  abdominal  wall; 
this  is  at  times  exceedingly  well  marked.  If  a  new  growth  causes 
tlie  narrowing,  in  addition  to  the  above  signs  a  tumor  may  be 
detected. 

Prognosis. — This  must  be  very  guarded.  Many  cases  Avith 
stricture  of  the  bowel,  under  careful  dietetics,  run  for  years  without 
serious  developments.  The  general  tendency  is,  however,  toward 
progressive  narrowing. 

Treatment. — By  careful  dietetics  and  attention  to  producing 
regular  alvine  evacuation,  preferably  by  enemata,  operative  treat- 
ment may  often  be  indefinitely  postponed.  When  symptoms  are 
progressive,  however,  operative  interference  must  be  counselled, 
particularly  before  the  onset  of  ou  acute  attack. 

Here  the  patient  is  in  fairly  good  condition,  the  surgeon  is  fully 


CHEONIC   OBSTRUCTION".  65 

prepared,  and  a  formal  and  complete  operation  can  be  performed 
with  a  prospect  of  success. 

If  the  narrowing  is  caused  by  a  cancer,  the  procedure  will 
depend  upon  whether  or  not  this  tumor  can  be  removed.  If  it 
can  be  removed,  total  extirpation  of  the  growth  together  with  the 
involved  gut  is  indicated  with  restoration  of  the  continuity  of  the 
intestinal  canal  by  Senn's  invagination  circular  enterorraphy,  or  by 
lateral  anastomosis.  In  case  this  cannot  be  performed  both  Ijowel 
ends  may  be  secured  in  the  parietal  wound,  with  the  idea  of  closing 
the  openings  by  a  subsequent  plastic  operation. 

If  the  malignant  growth  cannot  be  removed  it  should  either  be 
switched  out  of  the  direct  alimentary  path  by  performing  a  lateral 
anastomosis  between  the  bowel  above  and  the  bowel  below  the  seat 
of  obstruction,  or,  as  the  last  and  least  desirable  resort,  but  safest 
in  so  far  as  immediate  danger  to  life  is  concerned,  an  artificial  anus 
may  be  formed. 

If  the  narrowing  is  non-malignant,  excluding  it  by  a  lateral 
anastomosis  will  be  found  easy  of  performance  and  effectual. 

The  mortality  of  resection  does  not  yet  justify  this  operation  when 
there  is  an  alternative,  even  though  the  latter  is  not  so  mechanically 
perfect  as  complete  removal  of  the  diseased  portion  and  immediate 
restoration  of  the  continuity  of  the  gut. 

As  a  form  of  lateral  anastomosis  the  coil  of  intestine  above  and 
the  one  below  the  constriction  may  be  secured  in  the  external  wound 
in  close  apposition.  By  opening  these  two  coils  an  artificial  anus 
will  be  made,  and  the  first  step  towards  restoring  the  continuity  of 
the  canal  will  be  taken.  Subsequently,  by  the  use  of  the  enterotome, 
and  the  performance  of  one  or  more  plastic  operations,  this  artificial 
anus  may  be  closed. 

This  is  far  more  tedious,  less  sure,  and,  we  think,  less  safe  than 
lateral  anastomosis  by  approximation  plates. 


CHAPTER  Yin. 

PERITONITIS. 

Peritonitis  is  such  a  frequent  and  grave  complication  of  intesti- 
nal obstruction  that,  in  discussing  the  latter  affection,  a  considera- 
tion of  the  former  cannot  be  omitted. 

The  intlammatiou  involving  the  serous  membrane  may  be  local 
or  general,  it  may  be  plastic  or  suppurative,  it  may  be  acute  or 
chronic.  Mikulicz'  considers  acute  peritonitis  under  the  following 
headings  : — 

1.  General  diffuse  -peritonitis,  causing  death  in  a  few  hours,  with 
at  first  slight  injection,  then  an  abundant  fibrinous  exudate  and  ful- 
minant sepsis. 

2.  Progressive  suppurative  peritonitis. — The  course  of  the  disease 
is  slow,  but  it  steadily  advances.  New  areas  are  constantly  in- 
volved in  the  suppurative  process. 

To  these  may  be  added  a  third  caption,  which,  though  not 
pathologically  or  clinically  identical  with  peritonitis,  has  been  so 
constantly  regarded  as  a  form  of  this  affection,  and  is  such  an  im- 
portant complication  of  intestinal  wounds  and  obstruction  that  it 
is  conveniently  considered  with  inflammation  of  the  peritoneum. 
This  condition  is  termed  by  Verchere,^  Intestino-peritoneal  septi- 
ccemia. 

Excluding  certain  cases  of  plastic  peritonitis,  as,  for  instance, 
that  which  occurs  in  peri-hepatitis,  or  at  the  seat  of  interference 
in  aseptic  abdominal  work,  it  may  be  safely  assumed  that  the 
disease  is  dependent  upon  micro-organisms  and  their  products ; 
that  it  is  consecutive  to  infection  from  either  the  abdominal  pari- 
etes,  the  intra-abdominal  organs,  or,  in  some  cases,  parts  still  more 
remote,  and  that  traumatism,  or  irritation  of  any  kind,  is  a  strong 
predisposing  factor  in  the  development  of  this  condition. 

Thus  Rinne^  has  experimentally  demonstrated  that  the  perito- 

1  Berlin.  Klin.  Woch.,  June  10,  1889. 

2  Cong.  Franc,  de  Chirur.,  1888,  p.  291. 

3  Archiv.  fiir  Klin.  Chirur.  v.,  p.  39. 


PERITONITIS.  67 

Ileum  can  absorb  from  its  cavity  large  quantities  of  septic  matter, 
which  may  subsequently  be  eliminated  without  harm  to  tlie  patient, 
provided  it  has  not  been  subject  to  insult  or  traumatisui.  Pavv- 
loski^  has  shown  that  non-pathogenic  microbes  and  filtered  and 
sterilized  digestive  secretions  do  not,  when  introduced  into  the 
abdominal  cavity,  produce  peritonitis.  On  the  other  hand,  the 
unfiltered  partly  digested  food,  and  very  small  quantities  of  the 
pathogenic  micro-organisms  produce  a  septic  hemorrhagic  inflam- 
mation of  the  peritoneum. 

Habershon,^  in  501  autopsies,  found  positive  evidence  in  over  50 
per  cen^.  to  the  effect  that  the  peritonitis  was  due  to  direct  exten- 
sion ;  in  no  instance  did  he  find  the  disease  existing  solely  in  the 
serous  membrane.  Hernia  represented  the  most  common  starting- 
point  of  the  inflammation,  after  which  perforation  of  the  intesti- 
nal canal  was  next  in  order. 

Leaving  out  of  the  question  those  cases  of  plastic  peritonitis 
which  are  conservative  in  their  nature,  and  the  symptoms  of  which 
are,  at  most,  local  pain  and  tenderness,  with  possibly  slight  fever 
and  tympany,  we  have  to  consider  the  symptomatology  of — 

Diffuse  septic  loeritonitis. — The  usual  cause  of  this  is  a  perforation, 
pathological  or  traumatic,  of  one  of  the  hollow  viscera  contained  in 
the  abdominal  cavity.  The  gall-bladder,  urinary  bladder,  stomach, 
or  intestines,  if  extensively  opened,  will  discharge  their  contents 
upon  a  large  surface  of  the  peritoneum,  and  unless  death  occurs  in 
a  few  hours  from  shock  or  virulent  septic  absorption,  will  produce  a 
difllise  inflammation  of  the  peritoneum,  characterized  by  an  exuda- 
tion of  blood-stained  serum  or  thin  fetid  pus.  There  are  no  exten- 
sive fibrinous  deposits. 

Progressive  fibro-purulent  peritonitis. — This  is  typefied  by  those 
cases  of  perforation  in  which,  the  aperture  being  small  and  extravasa- 
tion being  slow  or  wanting,  there  is  time  for  a  reactive  inflammation 
to  cut  off  the  infected  area  from  the  general  peritoneal  cavity  by  an 
abundant  deposit  of  plastic  lymph  and  tight  peritoneal  adhesions. 
There  is  a  progressive  extension  of  the  process  with  frequently 
many  foci  of  septic  matter  incapsulated  between  the  adherent 
viscera. 

1  Internal.  Klin.  Rundsch.,  March  17,  1889. 

2  Diseases  of  the  Abdomen.     Second  ed.    London,  1862,  p.  555 


68  WOUNDS   AND    OBSTRUCTION    OF   THE    INTESTINES. 

It  is  well  known  tliat  nearly  all  cases  of  obstruction  terminating 
fatally  are  complicated  by  peritonitis,  even  though  no  perforation 
can  be  demonstrated ;  the  distended  and  congested  bowel  wall 
allowing  free  passage  of  septic  irritating  matter.  This  peritonitis, 
not  due  to  perforation,  is  at  first  a  progressive  fibro-purulent  form, 
though  it  may  be  suddenly  converted  to  a  diffuse  form. 

Intestino-peritoneal  Septicemia.  —  Under  this  heading 
Verchere  describes  an  abdominal  affection  characterized  by  consti- 
tutional symptoms,  with  locally  marked  mefeorism.  Death  occurs, 
usually,  between  the  eighth  and  twelfth  day  ;  rarely  befi^re  the 
sixth  day.  At  the  autopsy  a  small  quantity  of  sero-sanguinolent 
fluid  is  found  in  the  peritoneal  cavity ;  this  is  at  times  fetid,  but 
no  adhesions,  no  signs  of  peritonitis  are  observed. 

It  was  for  this  condition  that  Marion  Sims,  who  described  it 
accurately  and  assigned  the  causative  role  to  septic  absorption,  ad- 
vised abdominal  section.  Barnard  and  St.  Laurent  have  also 
clearly  described  the  condition,  as  has  Jobert  under  the  heading 
"  A  Latent  Form  of  Peritonitis,  of  which  Meteorism  is  the  most 
Characteristic  Symptom." 

The  cause  for  the  constitutional  symptoms  of  this  form  of  ab- 
dominal trouble,  which  is  commonly  termed  peritonitis,  is  probably 
filtration  and  absorption  of  the  septic  products  of  decomposition 
within  the  bowel. 

Symjjfoms  of  acute  peritonitis. — AYliere  inflammation  is  due  to 
perforation  the  onset  is  usually  sudden,  and  is  characterized  by  in- 
tense pain  with  symptoms  of  collapse ;  this  latter  condition  may 
rapidly  become  more  marked,  and  the  patient  may  perish  in  the 
course  of  a  few  hours.  Commonly,  the  pain  is  shortly  followed  by 
abdominal  distention  and  tenderness. 

The  respirations  are  entirely  thoracic,  the  diaphragm  being  either 
paralyzed  by  extensive  inflammation  or  not  acting  on  account  of 
pain. 

The  pulse  is  commonly  rapid  and  wanting  in  power ;  during  the 
height  of  the  inflammation  it  may  be  hard  and  small,  the  so-called 
wiry  pulse. 

There  is  obstinate  vomiting  of  thin,  bile-stained  matter,  and  the 
bowels  are  confined. 


PEEITONITIS.  G9 

The  miisoles  of  the  intestinal  walls  are  quickly  paralyzed  from 
involvement  in  the  inflammatory  action,  jieristalsis  ceases  aljso- 
lutely,  nor  can  it,  when  the  disease  is  well  developed,  be  re-estab- 
lished by  salines  or  any  other  form  of  medication. 

On  deep  pressure  friction  sensation  may  be  felt,  and  on  the  au- 
thority of  Batty  and  Chaumel  friction  sounds  are  readily  detected 
on  auscultation. 

The  position  of  the  patient  is  upon  the  back  with  the  thighs 
flexed  upon  the  pelvis.  The  face  is  characteristic  in  expression  ; 
always  very  pale,  thus  differing  from  nearly  all  acute  inflamma- 
tions, and  with  a  peculiar  pinched  anxious  expression. 

There  is  frequently  retention  of  urine,  nearly  always  a  very 
scanty  secretion  of  this  fluid. 

The  temperature  varies  greatly,  generally  ranging  high  through- 
out the  course  of  the  disease  and  becoming  subnormal  before  death. 

Hiccough,  subnormal  temperature,  and  a  pulse  increasing  in 
frequency  and  decreasing  in  volume  and  strength  are  certain  signs 
of  rapidly  approaching  dissolution.     The  mind  is  commonly  clear. 

To  these  symptoms  are  frequently  added  those  of  acute  intestinal 
obstruction,  since  paralysis  and  distention  of  the  bowel  commonly 
prevent  the  natural  passage  of  its  contents.  These  cases  usually 
terminate  in  death  in  from  twenty-four  to  forty-eight  hours. 

The  symptoms  of  the  progressive  suppurative  peritonitis  are 
similar  in  nature  to  those  of  the  general  diffuse  inflammation,  but 
produce  less  marked  effect  upon  the  system  at  large.  The  inflam- 
mation of  the  serous  membrane  accompanying  suppurative  typhlitis 
is  typical  of  this  form  of  inflammation. 

The  pain  may  be  as  great,  but  is  more  localized.  The  tenderness 
is  especially  marked  at  the  focus  of  inflammation,  and  in  the  direc- 
tion towards  which  it  is  extending.  In  addition  palpation  will  often 
reveal  a  distinct  tumor  in  which  fluctuation  may  be  perceived. 

Though  distention  and  tympany  are  usually  pronounced,  they 
do  not  reach  the  extent  common  in  the  diffuse  inflammation. 

The  pulse  is  usually  quick  and  full.  The  breathing  is  not  so 
markedly  thoracic,  the  vomiting  is  often  absent,  constipation  is 
stubborn,  but  can  be  overcome. 

The  temperature  is  akin  to  that  of  inflammation  in  any  other 


70  WOUNDS    AND   OBSTRUCTION   OF    THE   INTESTINES. 

part  of  the  body,  ranging  between  100°  and  104°.     The  pinched 
pallid  sunken  face  is  not  observed. 

This  form  of  inflammation  may  at  any  time  cause  obstruction, 
or  may,  by  the  bursting  of  an  encapsulated  purulent  deposit  into 
the  general  peritoneal  cavity,  become  diffuse,  in  which  case  the 
symptoms  characteristic  of  these  conditions  will  quickly  develop. 

Intestino-peritoneal  Septicemia. — In  place  of  the  violent 
outbreak  so  common  in  peritonitis  the  disease  begins  insidiously. 
There  may  be  at  first  shock,  but  no  complaint  of  marked  abdominal 
pain  or  tenderness. 

The  abdominal  facies  is  usually  the  first  symptom,  characterized 
by  the  hollow  dark-ringed  eyes,  the  sunken  cheeks,  the  pinched 
nose,  and  the  preternatural  calmness  of  expression.  At  times  there 
is  absolutely  no  other  sign  of  grave  trouble  on  inspection  till 
immediately  before  death. 

The  pulse  is  always  frequent,  the  temperature  normal  or  sub- 
normal till  just  before  death,  when  it  suddenly  rises.  The  ratio 
between  pulse  and  temperature  is  particularly  suggestive,  the  one 
running  above  140  and  often  the  other  not  rising  above  98.2. 

The  most  characteristic  sign  in  connection  with  the  abdomen  is 
the  marked  tympanitic  distention.  This  is  not  accompanied  by 
either  pain  or  tenderness  at  any  time  in  the  course  of  the  case. 

There  is  vomiting,  first  of  the  contents  of  the  stomach,  then  of 
bile,  finally  of  fecal  matter.  Death  usually  takes  place  between 
the  eighth  and  twelfth  day. 

The  autopsy  shows  that  there  is  no  pus  and  no  adhesions,  that 
the  bowel  is  greatly  distended,  and  that  there  is  in  the  dependent 
parts  of  the  abdominal  cavity  a  little  sero-sanguinolent  fluid,  some- 
times ill-smelling  and  containing  micro-organisms.  Extravasation 
of  fecal  matter  is  not  found  in  these  cases. 

After  traumatism,  wounds  of  the  intestines,  intestinal  strangula- 
tion, sudden  obstruction  from  any  cause  or  insult  to  the  abdominal 
contents  in  the  course  of  prolonged  operations  involving  their 
exposure,  this  train  of  symptoms  not  unfrequently  develops,  and 
is  ascribed  by  Verchere  to  the  retention  and  filtration  of  intestinal 
gas,  micro-organisms,  or  ptomaines.  Examinations  of  the  blood 
have    not   shown    the   presence   of   micro-organisms,   hence    it    is 


PERITONITIS.  71 

probable  that  it  is  their  products,  and  not  tliemselves,  which  are 
responsible  for  the  train  of  symptoms  described. 

It  will  be  recognized  at  once  that  a  great  number  of  individual 
cases  present  a  combination  of  the  symptoms  of  the  different  con- 
ditions described,  rather  than  the  typical  course  of  either  diffuse, 
or  spreading  peritonitis,  or  abdominal  septicaemia.  This  is  because 
these  conditions  may  complicate  each  other.  Thus  given,  a  case  of 
acute  purulent  peritonitis,  or  the  S])reading  form  of  this  inflamma- 
tion, complicated,  as  it  frequently  is,  with  obstruction,  if  tlie  bowel 
contains  large  quantities  of  putrescent  matter,  fermentation  and 
gas  formation  are  exceedingly  rapid,  the  ptomaines  are  absorbed  in 
large  quantities,  and  in  place  of  pain  and  fever  the  toxic  symptoms 
may  prevail.  The  characteristic  features  of  abdominal  septicaemia 
may  mark  the  case,  the  normal  or  subnormal  temperature  and  the 
absence  of  pain  and  tenderness  often  conveying  a  belief  in  amelio- 
ration in  the  condition  of  the  patient  which  the  weak,  running 
pulse  should  at  once  dispel. 

At  times  there  is  not  only  absence  of  pain  and  tenderness,  but 
there  may  be  no  sign  of  tympanitic  distention,  though  the  abdomi- 
nal cavity  may  be  full  of  pus.  These  cases  are  marked  by  the 
character  of  the  pulse  and  by  a  peculiar  board-like  hardness  of  the 
abdominal  muscles.  This  latter  sign  is,  however,  not  always 
present.  To  account  for  this  w^ant  of  tympany,  no  other  expla- 
nation is  needed  than  absence  in  the  alimentary  canal  of  ferment- 
able substances,  or  presence  of  certain  chemical  agencies  which  pre- 
vent this  fermentation.  It  is  probable  that  the  same  paralysis  of 
the  intestinal  walls  exists  as  in  other  cases,  but  that  there  is  not 
present  the,  at  times,  enormous  pneumatic  pressure  developed  by 
the  decomposition  of  organic  bodies.  The  septic  absorption  in 
these  cases  would  come  from  the  pus  in  the  peritoneal  cavity  rather 
than  from  the  bowel  contents. 

The  violence  of  the  symptoms  is  by  no  means  commensurate 
with  the  septic  matter  inclosed  within  the  peritoneum.  Sims, 
Baudens,  and  many  others  have  observed  that  death  resulted  when 
only  an  ounce  or  two  of  non-offensive,  blood-stained  serum  was 
found  in  the  abdominal  cavity.  Musser^  records  the  successful 
issue  of  a  case  from  which  three  gallons  of  bloody,  purulent  fluid 
were  withdrawn  by  means  of  a  canula. 

1  University  Med.  Mag.,  vol.  1,  p.  273. 


72  WOUNDS    AND   OBSTRUCTION    OF   THE   INTESTINES. 

It  would  seem  tliat,  where  the  inflammation  is  from  the  first 
sufficiently  violent  to  block  the  lymphatics,  there  is  compara- 
tively, a  moderate  amount  of  septic  absorption ;  where  these  ves- 
sels still  preserve  their  physiological  capabilities,  and  the  amount 
of  septic  matter  is  so  great  that  it  overwhelms  the  emunctories,  the 
t}^ical  symptoms  of  intestinal  septicaemia  are  developed. 

Diagnosis. — In  typical  cases  the  diagnosis  is  easy.  Fever,  vom- 
iting of  bile,  constipation,  pain,  tenderness,  tympanitic  distention, 
absence  of  abdominal  breathing,  and  ra])id  pulse,  if  present,  so 
clearly  characterize  the  nature  of  the  complaint  that  a  mistake  is 
scarcely  possible.  Cramps  from  muscular  spasm  or  possibly  tempo- 
rary invagination,  pain  from  gall-,stones  or  renal  calculi,  pressure, 
effects  of  abdominal  tumors,  pus  formation  in  the  abdominal  walls, 
although  presenting  individually  certain  of  the  characteristic  symp- 
toms of  peritonitis,  never  present  the  complete  picture  of  inflamma- 
tion of  the  serous  membrane,  and,  moreover,  present  features,  pecu- 
liar to  themselves,  which  will  usually  render  a  diagnosis  practicable. 
While  the  diagnosis  cannot  immediately  be  made  in  some  cases,  by 
waiting  a  few  hours  the  presence  or  absence  of  peritonitis  usually 
becomes  clear. 

From  obstruction,  peritonitis  is  distinguished  with  some  diffi- 
culty, since  one  condition  usually  complicates  the  other.  Perito- 
nitis, with  its  rapid  onset,  absence  of  peristalsis,  and  excessive  ten- 
derness, is  to  be  contrasted  with  the  violent  peristalsis,  the  steady 
advance  of  symptoms,  and  the  moderate  tenderness  of  intestinal 
obstruction  in  its  early  stages.  In  many  cases  the  dividing  line 
cannot  be  drawn,  and  Le  Fort,  Kronlein,  and  Mikulicz  have  all 
operated  for  the  relief  of  obstruction  and  found  the  patient  suffer- 
ing from  a  perforative  peritonitis. 

Rheumatism  of  the  abdominal  walls  can  be  a  cause  of  doubt  only 
for  a  short  time,  and  the  rheumatic  peritonitis  usually  shows  its 
nature  by  sudden  transference  of  symptoms  to  other  parts  of  the 
body,  and  by  prompt  yielding  to  the  effects  of  anti-rheumatic 
treatment. 

The  scanty,  high-colored  urine  is  not  in  any  way  diagnostic, 
since  all  intra-abdominal  affections  accompanied  by  persistent  vom- 
iting are  characterized  by  similar  alterations  of  this  fluid. 


PERITONITIS.  73 

Treatment. — This  must  depend  upon  the  origin  and  upon  the 
particular  form  of  the  inflammation.  In  general  terms  it  maybe 
stated  to  be  either  surr/ical  or  medical.  Each  method  has  its  indi- 
cations, and  each,  if  properly  used,  will  give  a  large  percentage  of 
success.  Thus  Bouilly,^  in  12  desperate  eases,  saved  0  by  abdomi- 
nal section.  Wagner,^  by  operation,  cured  a  case  of  perforative 
peritonitis  due  to  relapsing  typhoid  ulcer.  Mikulicz^  states  that  of 
74  cases  reported  by  two  authors  28  recovered.  Kocnig,  Kosen- 
berger,  Stelzner,  Tait,  and  others  have  recorded  many  successful 
cases. 

From  the  medical  side  of  the  question  Musser  gives  the  histories 
of  19  cases  of  septic  peritonitis,  all  of  whom  recovered  without  ope- 
ration. In  addition  he  records  7  puerperal  cases,  with  3  deaths. 
In  all  he  has  treated  29  cases,  with  3  deaths ;  22  cures  by  medical 
means  and  4  cures  by  operation.  Obalinski*  strongly  favors  the 
expectant  treatment  even  when  the  inflammation  is  complicated  by 
obstruction.     Of  12  cases  thus  treated  9  recovered. 

Operative  Treatment. — Mikulicz  states  that  many  patients 
are  directly  injured  by  operation,  and  that  recovery  after  operation 
seems  to  depend  less  upon  the  procedure  adopted  than  upon  acci- 
dent. Thus  Demons,^  with  a  rough  sponge  and  knife-blade, 
scraped  the  entire  surface  of  the  intestine  in  a  case  of  purulent 
peritonitis  following  suppuration  of  an  ovarian  cyst,  and  the  pa- 
tient made  a  rapid  recovery. 

In  regard  to  general  diffuse  peritonitis,  whether  dependent  upon 
perforation  and  extravasation  or  not,  there  is  a  growing  belief  that 
prompt  abdominal  section,  abundant  washing  of  the  peritoneal 
cavity  with  hot  solutions,  closing  of  the  visceral  opening,  if  one 
exists,  and  drainage,  offer  by  large  odds  the  best  hope  of  recovery. 
In  addition  to  this  the  tympany  should  be  relieved  by  one  or  more 
quarter-inch  incisions  into  the  convex  surface  of  the  gut,  the  in- 
testinal tube  should  be  washed  with  a  weak  solution  of  naphthol 
or  other  mild  antiseptic,  to  prevent  continuance  of  fermentation 

1  Le  Bulletin  Med.,  Oct.  13,  1889. 

2  Cong,  der  Deutscli.  Gesel.  f.  Chirur.  Berlin.  Klin.  Woch.,  June  10,  1889. 

3  Berlin.  Klin.  Woch.,  June  10,  1889. 

*  XVI.  Versamm.  Deutsch.  Chirurg.,  1887. 

5  French  Surg.  Cong.  Le  Bull.  Med.,  Oct.  13,  1889. 


74  WOUNDS    AND    OBSTRUCTION    OF    THE    INTESTINES. 

and  renewal  of  distention,  and  ]>rovision  slioidd  be  made  for  re- 
l)eatcd  irrigation  with  hot  (100-110°  F.)  sterilized  salt  .solution 
(sevea-tenths  of  one  per  cent.),  several  tubes  being  carried  to  the 
various  parts  of  the  al)dominal  cavity,  and  the  latter  l)eing  flushed 
out  ever}:  hour  until  the  formation  of  adhesions  prevents  this. 

Nothing  should  be  given  by  the  mouth  except  intestinal  anti- 
sejjtics  such  as  naphthol,  salol,  or  salicylic  acid. 

As  stimulants  are  most  important  they  should  be  given  freely, 
either  by  the  rectum  or,  better,  by  means  of  hypodermic  medica- 
tion, thus  saving  this  portion  of  the  bowel  for  the  absorption  of 
peptonoids  and  other  nutrient  enemata.  For  this  purpose  an  ounce 
of  brandy  may  be  dissolved  in  eight  ounces  of  sterile  water  and 
slowly  injected  by  means  of  gravity  into  the  subcutaneous  or  mus- 
cular tissues  of  the  buttocks,  abdominal  walls,  or  other  thick, 
fleshy  region.  For  sudden  prostration,  hypodermics  of  ether, 
twenty  minims  pure,  forced  directly  into  the  muscles,  and  re- 
peated six  or  eight  times  at  short  intervals,  will  be  found  most 
efiicacious. 

Progressive  Suppurative  Peritonitis.  —  The  advice  of 
Treves  in  the  treatment  of  this  condition,  as  developed  by  in- 
flammation about  the  caecum,  that  is  to  open  and  evacuate  the 
purulent  collections  without  breaking  through  the  wall  which 
separates  them  from  the  rest  of  the  abdominal  cavity,  should 
dominate  the  surgeon  in  the  treatment  of  this  form  of  peritonitis, 
no  matter  what  its  origin  or  seat  may  be ;  and  it  is  to  the  neglect 
of  this  practice  that  many  deaths  must  be  ascribed.  Mikulicz 
operated  upon  five  cases  of  this  character.  On  two  of  these  cases 
he  operated  several  times,  opening  each  new  accumulation  of  pus 
as  it  was  discovered.  The  cavities  were  washed  out  ^vith  salt  solu- 
tion ;  even  if  the  gut  was  perforated,  no  attempt  was  made  to 
suture  it  unless  the  wound  was  accessible ;  drainage  was  provided 
for  by  iodoform  gauze  tamponade;  a  few  sutures  were  placed  in  the 
parietal  wound.  The  two  cases  thus  treated  recovered,  while  three 
treated  in  the  usual  manner  perished. 

In  these  cases  there  is  often  no  great  urgency ;  the  course  is  one 
of  weeks  or  even  months.  Suppuration  is  denoted  by  hectic  or 
simply  by  night-sweats  and  by  loss  of  flesh  and  strength.  Sooner 
or  later  dulness  on  percussion,  local  pain  or  tenderness,  and  the 


PEEITONITIS.  75 

signs  of  tumor,  point  to  the  seat  of  trouble.  These  cases,  if  gene- 
rally treated  on  the  lines  laid  down  by  Mikulicz,  are  destined  to 
present  a  far  smaller  mortality  than  heretofore. 

Intestino-peritoneal  Septicaemia. — Although  it  is  gene- 
rally stated  that  these  cases  are  beyond  hope  and  that,  barring 
the  medical  treatment,  nothing  should  be  attempted,  we  are  pro- 
foundly convinced  that  prompt  abdominal  section  and  washing  out 
of  the  peritoneum,  together  with  many  incisions  into  the  gut,  and 
cleansing  of  it  with  mild  antiseptic  agents,  will  be  of  service.  Thus 
will  be  removed  the  source  of  septic  absorption,  and  even  though  a 
new  supply  be  forthcoming  the  system  will  have  had  a  respite  in 
which  to  gather  strength  for  the  struggle  against  toxsemia.  Stimu- 
lants forced  to  their  extreme  limits  are  indicated  in  these  cases  and 
are  best  given  subcutaneously.  Lavage  of  both  stomach  and  colon 
should  be  employed. 

There  remain  many  cases  of  peritonitis  in  which  the  knife  can 
be  productive  of  no  good,  cases  without  suppuration,  and  present- 
ing no  evidences  of  bowel  obstruction ;  or  possibly  with  symptoms 
of  both  these  conditions,  dependent  upon  intestinal  paralysis.  In 
all  cases  of  peritonitis,  except  those  which  break  out  with  virulent 
intensity,  we  believe  that  the  first  thought  of  the  attendant  should 
be  a  resort  to  medical  treatment. 

Considering  the  disease  from  the  standpoint  of  the  therapeutist, 
an  inflammation  of  the  peritoneum,  as  in  the  case  of  any  serous 
membrane,  may  be  either  sthenic  or  asthenic.  The  same  rules 
hold,  therefore,  in  this  case  as  in  all  forms  of  inflammation, 
namely,  that  circulatory  depressants  are  only  to  be  used  in  the 
first  type  and  followed,  if  needed,  by  stimulants ;  whereas  in  the 
asthenic  class  the  use  of  stimulants  is  called  for  at  once  and  de- 
pressants are  contra-indicated.  For  many  years  the  profession 
has  recognized  opium  and  belladonna,  particularly  the  former, 
as  the  most  universally  applicable  remedies  and  best  curative 
drugs  for  cases  of  peritoneal  inflammation,  and  while  a  new 
school  of  treatment  in  this  disease  has  arisen,  it  has  only  proved 
itself  of  value  in  certain  cases. 

In  so  far  as  the  treatment  of  the  inflammation  is  concerned  the 
course  to  be  pursued  is  fairly  plain. 


76  WOUNDS   AND    OBSTRUCTION    OF   THE   INTESTINES. 

AVhile  the  use  of  veratrum  viride  may  be  resorted  to  where  the 
patient  is  strong  and  the  pulse  hard  and  ten.se,  aconite  may  per- 
haps, in  such  cases,  be  better,  for  the  double  reason  that  vomiting 
is  apt  to  occur  of  itself  and  may  be  induced  by  the  veratrum  viride, 
Avliile  aconite  decidedly  prevents  any  such  tendencies.  This  is  im- 
portant in  view  of  the  fact  that  vomiting  always  is  to  be  avoided, 
lest  the  retching  increase  the  peritoneal  inflammation. 

If  vomiting  and  pain  are  present,  they  should  be  controlled  by 
the  use  of  full  doses  of  opium  and  belladonna,  say  one-quarter  of 
a  grain  of  the  extract  of  each  to  an  adult,  and  the  application  of 
leeches  to  the  abdominal  wall  in  large  number  (from  10  to  30)  or 
the  use  of  counter-irritants.  If  the  vomiting  is  too  severe  to  take 
the  drugs  by  the  mouth,  they  must  be  given  by  the  rectum  in  a 
half  pint  of  starch-water,  laudanum  and  the  tincture  of  belladonna 
being  employed  in  the  proportion  of  half  a  drachm  each,  or  the 
alkaloids  may  be  given  hypodermically. 

Opium  is  always  well  borne  in  full  doses  by  those  suffering  se- 
vere pain,  and  it  seems  to  be  particularly  well  borne  in  peritonitis. 
The  use  of  the  drug  here,  as  everywhere  else  in  medicine,  is  not 
governed  by  the  amount  which  has  been  used,  but  by  the  effects 
which  it  produces.  Opium  and  belladonna,  unlike  the  depressants 
and  stimulants,  may  be  used  in  all  stages  of  peritonitis,  if  called 
for,  but  the  leeches  and  counter-irritants  are  limited  in  their  use 
to  early  periods  of  the  attack. 

The  use  of  calomel  in  peritonitis  is  highly  praised  by  some  and 
decried  by  others,  largely  because  its  proper  sphere  is  not  recog- 
nized. Mercury  does  good  only  in  the  severe  acute  forms  of  peri- 
tonitis where  the  disease  arises  from  traumatism  or  other  cause,  and 
is  not  to  be  used  except  for  the  changing  of  a  fibrinous  exudate 
into  one  incapable  of  undergoing  organization. 

Absolute  rest  and  the  administration  of  stimulants  and  food  by 
the  rectum  till  stomach  becomes  retentive  must  be  enforced. 

Commonly  in  peritonitis  the  inflammation  involves  the  muscular 
layer  of  tlie  bowels.  As  a  result  of  this  obstinate  constipation 
ensues,  which  is  not  always  to  be  overcome  by  purges,  which,  if 
they  are  mild,  will  not  act,  and  if  severe  are  dangerous,  but 
by  the  use  of  belladonna  and  opium  already  spoken  of.  The 
rationale  of  this  treatment,  in  the  light  of  our  present  physiological 
knowledge,  is  not  far  to  seek.     Belladonna  acts  as  an  antispas- 


PERITONITIS.  77 

modic  upon  all  unstripcd  mnscular  fibre,  and  in  the  large  doses  here 
given  depresses  the  peri])heral  ends  of  the  splanchnic  or  inhibitory 
intestinal  nerves.  In  this  way  the  muscular  fibres,  which  are  in 
spasm,  are  relaxed  and  the  peristaltic  waves  set  free.  The  value 
of  the  opium  also  is  apparent,  for  it  allays  and  prevents  the  reflex 
muscular  spasm  and  hence  the  pain  and  inflammation.  Obstinate 
constipation  after  the  ingestion  of  irritant  foods,  such  as  putrid  meat, 
will  often  be  relieved  by  opium  and  belladonna  as  effectively  as  if 
the  patient  was  purged  by  an  ordinary  purgative. 

Very  frequently  in  acute  peritonitis  tympanitis  becomes  not  only 
a  very  painful,  but  even  a  dangerous  symptom,  the  distention  of 
the  belly  being  very  great.  This  may  be  greatly  relieved  by  the 
employment  of  turpentine  stupes,  and  in  some  cases  by  the  rectal 
injection  of  the  milk  of  asafoetida,  or  better  still :  turpentine,  1 
drachm  ;  milk  of  asafoetida,  3  ounces  ;  and  warm  water,  4  ounces. 

Not  content  with  having  made  a  vast  stride  forward  during  the 
past  few  years,  abdominal  surgery  brings  with  it  not  only  new 
methods  of  treating  disease  in  this  region  by  the  knife,  but  also 
has  given  us  a  method  of  healing  peritonitis  by  the  use  of  saline 
purgatives,  which  is  certainly  of  greatest  value  in  those  sudden 
inflammatory  conditions  which  occasionally  spring  into  life  after 
operations  upon  the  abdominal  contents.  It  will  be  remembered  that 
Mr.  Lawson  Tait  has  been  the  chief  advocate  of  this  treatment  for 
several  years,  and  that  the  wonderful  results  which  he  obtained,  the 
reputation  of  the  reporter,  and  the  complete  reversal  of  all  our  ideas 
concerning  the  treatment  of  the  disease,  have  called  forth  not  only 
an  enormous  number  of  trials  of  the  method  in  this  country,  but 
have  also  brought  forth  two  opposing  factions  in  the  profession.  The 
first  of  these  is  chiefly  of  surgeons;  the  second  of  persons  who,  in  a 
long  experience,  have  reached  good  results  by  older  methods,  and 
who  are  generally  physicians.  The  first  class  dogmatically  assert 
that  the  physician  should  turn  over  every  case  of  peritonitis  to  the 
surgeon  to  be  opened,  searched,  and  purged ;  the  second  class  do  not 
deny  that  saline  purgatives  do  good  in  the  hands  of  the  surgeon, 
but  are  more  conservative  in  their  opinions  concerning  the  general 
use  of  such,  measured  in  all  cases  of  peritonitis. 

Again,  it  would  seem  to  be  impossible  at  the  present  time  to 
assert  that  peritonitis  may  be  either  idiopathic  or  traumatic  with- 
out bringing  upon  one's  head  a  storm  of  criticism,  for  on  the  one 


78  WOUNDS   AND   OBSTRUCTION   OF   THE   INTESTINES. 

side  we  have  a  number  of  pliysicians  who  believe  that  peritonitis 
may  arise  without  any  direct  exciting  cause,  and  on  the  other  hand 
an  equally  large  body  of  observers  who  assert  that  it  is  essentially 
a  secondary  inflammation  brought  about  by  direct  contiguity  with 
an  already  inflamed  tissue ;  or  else  that  the  inflammation  is  set  up 
by  the  escape  of  foreign  bodies  into  the  peritoneal  cavity,  or  by 
pathological  changes  in  organs  normally  situated  in  these  regions, 
as,  for  example,  fibroid  enlargements  of  the  uterus  with  impaction 
in  the  pelvis,  or  pyosalpynx. 

As  it  is  absolutely  impossible  for  either  side,  at  present,  to  prove 
that  their  opponents  are  wrong,  and  as  both  sides  are  not  to  be 
doubted  in  the  integrity  of  their  observations,  the  unbiased  judge 
can  but  come  to  the  conclusion  that,  as  yet,  we  have  a  right  to  be- 
lieve that  idiopathic  peritonitis  may  exist. 

If  those  observers  are  correct  who  believe  that  no  peritonitis 
arises  save  as  the  result  of  some  one  of  these  conditions,  then  the 
attempt  on  the  part  of  the  physician  to  treat  such  a  case  is  crimi- 
nal negligence,  and,  as  such,  cannot  be  too  severely  condemned ; 
but  too  many  cases  of  peritonitis  are  to-day  walking  examples  of 
the  value  of  the  use  of  opium  to  permit  of  any  one  asserting  that 
this  treatment  is  useless,  or  that  the  knife  of  the  surgeon  is  to  be 
used  in  every  case ;  yet  some  of  the  more  positive  members  of  the 
profession  would  have  us  believe  the  abdomen  should  be  opened 
solely  for  the  purpose  of  making  a  diagnosis,  and  that  this  having  been 
done  and  no  intestinal  complications  found,  salines  should  be  given. 

Whether  the  inflammation  be  idiopathic  or  not  has  little  to  do, 
however,  with  the  methods  which  we  are  to  resort  to  in  the  medi- 
cal treatment  of  this  condition.  It  cannot  be  gainsaid  that  the 
results  obtained  by  surgeons  in  the  use  of  saline  purgatives  have 
been  startlingly  brilliant,  neither  can  any  one  deny  that  their 
methods  may  sometimes  be  employed  in  medicine  as  well  as  in 
surgery ;  but  there  are  several  points  to  be  recalled  by  both  parties 
which,  we  think,  so  seriously  modify  the  views  of  each  as,  after  all, 
to  somewhat  harmonize  their  views.  No  one  denies  that  the  sur- 
geon does  rightly  when  he  uses  salines  to  prevent  peritonitis,  after 
an  operation,  but  the  knowledge  of  the  condition  of  the  patient 
after  he  has  been  operated  upon  by  the  surgeon,  and  that  possessed 
by  the  physician  when  called  to  see  a  case  of  peritonitis,  are  radi- 
cally different,  for  the  surgeon  has  a  right  to  believe  that  the 


PERITONITIS.  79 

intestinal  canal  is  patulous  and  dovoid  of  impactions  and  intussus- 
ceptions, while  the  latter  knows  not  whether  he  lias  before  him  an 
inflammation  of  the  peritoneum  without  intestinal  involvement,  or 
inflammation  dependent  npon  some  abnormality  in  the  primje  v'lUi. 
As  a  consequence,  it  is  perfectly  proper  for  surgeons  to  administer 
salines  which,  to  use  their  own  words,  not  only  deplete  the  abdom- 
inal bloodvessels,  but  also,  by  the  increased  peristaltic  movements 
produced,  prevent  adhesions ;  while  the  physician  in  the  case  of 
peritonitis  from  perforation,  impaction,  or  intussusception,  may  do 
the  patient  an  immense  amount  of  harm  by  such  a  procedun;  long 
before  it  is  possible  to  decide  what  the  cause  of  the  trouble  may  be. 

It  is  evident,  therefore,  that  the  opium  treatment  must  be  ad- 
hered to,  at  least  until  the  diagnosis  is  formed,  unless  at  the  first 
sign  of  pain  an  exploratory  incision  is  made  instead  of  using  those 
remedies  generally  employed  in  ordinary  attacks  of  abdominal  dis- 
comfort ;  and  it  should  not  be  forgotten  that  pain  and  tenderness 
with  inflammation  are  not  only  the  symptoms  of  peritonitis  after 
section,  but  also  of  many  other  states  in  the  ordinary  individual. 

It  is  also  evident  that  other  conditions  may  exist  which  render 
the  administration  of  purges  unjustifiable,  and  in  which  the  use  of 
the  knife  by  the  surgeon  is  not  to  be  thought  of.  It  is  undeniable 
that  the  surgeon  should  be  summoned  the  moment  a  suspicion  of 
perfoi'ation  arises,  but  in  the  case  of  a  person  in  whom  an  enteritis 
has  arisen,  locally,  by  an  old  adhesion,  increased  peristaltic  move- 
ment is  equivalent  to  strapping  the  normal  side  of  the  chest  in 
pleurisy,  with  the  object  of  giving  the  diseased  side  more  exercise. 

Again,  it  is  of  the  gravest  importance  that  both  the  physician 
and  surgeon  should  distinguish  very  clearly  between  an  inflamma- 
tion of  the  peritoneum  in  a  strong  healthy  j)erson,  and  in  one  who 
is  in  a  condition  of  vital  depression,  or  exhausted  from  prolonged 
disease  elsewhere.  Depletion  by  means  of  purges  is  of  course,  in 
the  first  class,  as  much  indicated  as  the  application  of  leeches  or 
bleeding,  but  in  the  second  class,  quite  as  strongly  contraindicated. 
Ill  the  dynamic  form  of  inflammation,  there  is  danger  of  adhesions 
being  formed  by  reason  of  the  fibrinous  exudate  thrown  out ;  in 
the  adynamic  condition  of  inflammation  there  is  already  an 
enormous  exudation  of  serum  into  the  abdominal  cavity,  which 
purges  cannot  remove  till  they  have  drained  oiF  a  large  amount 
of  liquid  from  the  blood. 


80  WOU^'DS   AMD   OBSTRUCTION   OF   THE   INTESTINES. 

Again,  there  are  some  cases  of  peritonitis  whicli  are  ushered  in 
by  an  acute  paroxysm  of  pain,  but  which  do  not  continue  during 
their  whole  course  as  dynamic  cases,  and  in  which  depletion  at  first 
results  in  exhaustion  later  on. 

Until  the  profession  have  employed  these  two  methods  side  by 
side,  with  an  absolutely  unbiased  opinion  for  a  long  period  of 
time,  the  only  proper  conclusion  to  be  reached  seems  to  us  to  be 
this,  namely,  that  in  acute  peritonitis  suddenly  lighted  up  in  a 
surgical  case,  and  Mdiich  is  recognized  almost  at  the  moment  of  its 
inception  by  the  surgeon,  who  is  ever  watchful  for  it,  salines  should 
be  given  ;  in  the  case  which  the  physician  rarely  sees  till  hours  liave 
elapsed,  and  in  which  grave  doubt  must  exist  as  to  the  cause  of  the 
trouble  opium  and  external  methods  of  depletion  must  be  resorted  to. 


CHAPTER  IX. 

ON    DIAGNOSING    THE    VARIOUS    FORMS    OF    INTESTINAL 
OBSTRUCTION. 

Each  of  the  comniou  forms  of  intestinal  obstruction  has  been 
considered  individually,  with  the  general  appropriate  treatment. 
It  is  now  in  order  to  discuss  the  differential  diagnosis  between  the 
various  forms  of  obstruction,  and  to  treat  in  more  minute  detail  the 
various  therapeutic  means  which  have  been  proposed  in  the  treat- 
ment of  this  class  of  affections. 

In  general,  the  symptoms  caused  by  occlusion  of  the  intestinal 
canal  are  the  same  :  pain,  ch'stention,  obstinate  constipation  and 
vomiting,  and  systemic  depression.  Each  form  of  obstruction  pre- 
sents certain  peculiarities,  but  these  are  unfortunately  not  constant. 
Hutchinson*  states  that  an  accurate  diagnosis  of  the  cause  of  ob- 
struction is  not  in  four  out  of  five  cases  possible.  Obalinski^  says 
that  a  diagnosis  cannot  be  made  in  more  than  half  the  cases. 
Depres,^  however,  holds  that  the  diagnosis  of  the  cause  can  be 
made  when  the  symptoms  are  well  developed  in  99  per  cent,  of  all 
cases.  With  this  statement  there  are  few  practical  surgeons  who 
will  agree.  $ 

At  the  very  beginning  of  the  question  comes  the  difficult  ques- 
tion of  distinguishing  between  eases  of  obstruction  due  to  mechan- 
ical occlusion  of  the  bowel  and  those  due  to  paralysis.  Where  the 
paralysis  is  the  result  of  a  frank  peritonitis,  the  pain,  tenderness, 
decubitus,  characteristic  vomiting,  tympany,  and  absence  of  peris- 
talsis, with  high  temperature  and  rapid,  wiry  pulse,  will  at  once 
suggest  the  diagnosis.  Where  it  is  attended  with  the  minimum 
amount  of  inflammation,  however,  or  where  the  septic  symptoms 
predominate,  it  may  be  impossible  to  decide  as  to  the  nature  of  the 
case.     Heusner^  reports  two  cases  in  which  laparotomy  for  obstruc- 

1  Archives  of  Snrg.,  Vol.  1,  No.  1,  p.  10. 

2  VI.  Langenbeck  Arch.  f.  Chirur.,  xxxviii.,  2. 

3  Rev.  de  Chir.,  1887.  <  Deut.  Med.  Woch.,  1SS7. 
6 


82  AVOUNDS    AXD    OBSTRUCTION   OF   THE    INTESTINES. 

tion  was  performed,  the  operation  sliowing  that  the  symptoms  were 
ilependcnt  upon  a  perforative  ])aralysis.  We  liave  an  unreported 
case  where  the  abdomen  was  opened  for  internal  strangulation 
Avheu  a  paretic  condition  of  the  bowel  dependent  upon  enteritis 
was  present.  Many  instances  of  failure  to  determine  between  these 
two  conditions  can  be  cited,  and  it  is  well  known  that  the  men  of 
greatest  experience  express  least  confidence  in  making  a  differential 
diagnosis. 

The  history  of  the  case  is  always  important.  A  previous  attack 
of  inflammation  would  suggest  bauds  or  adhesions.  A  record  of 
typhoid,  or  other  ulceration  of  the  bowel,  would  suggest  stricture ; 
a  history  of  anomalies  in  the  family  would  suggest  a  Meckle's 
diverticulum.  An  account  of  abdominal  traumatism  would  suggest 
hernia  through  rents  in  the  mesentery  or  omentum  ;  a  history  of 
stubborn  constipation  would  suggest  volvulus,  impaction  of  feces, 
adhesion,  or  stricture. 

Age  and  sex  must  be  considered — infants  are  prone  to  intussus- 
ception, young  adults  to  internal  strangulation,  adult  females'  to 
fecal  impactions.  Males  at  about  middle  age  or  somewhat  past  it, 
to  volvulus,  this  condition  being  exceedingly  rare  before  the  twenty- 
fifth  year. 

Onset.— This  will  serve  to  distinguish  the  acute  from  the  chronic 
forms  of  obstruction.  If  it  occurs  suddenly  in  a  j^erson  of  good 
health,  not  presenting  previous  bowel  symptoms,  and  especially  if 
dependent  upon  some  sudden  or  violent  muscular  exertion,  the 
chances  are  greatly  in  favor  of  internal  strangulation  being  the 
causative  condition.  Frequently,  however,  a  violent  outbreak  with 
fulminant  symptoms  is  found  to  depend  upon  a  chronic  form  of 
obstruction. 

Pain  and  shock. — These  symptoms  are  usually  best  marked  in 
cases  of  internal  strangulation.  They  both,  however,  depend  in 
the  beginning  upon  the  amount  of  constriction  to  which  the  bowel 
is  subject,  and  they  may  be,  exceptionally,  well  marked  from  the 
first  in  volvulus  or  invagination.  The  seat  of  pain  should  be  care- 
fully considered,  since,  if  it  is  correctly  referred  to  the  position  of 
the  obstruction,  and  this  is  occasionally  the  case,  it  may  be  a  valu- 
able diagnostic  guide. 

1  Treves,  London  Lancet,  1887. 


DIAGNOSING   VARIOUS   FORMS   OF   INTESTINAL   OBSTRUCTION.      83 

Temperature. — This  makes  no  great  departure  from  normal  till 
peritonitis  sets  in,  when  it  may  be  moderately  elevated.  In  disten- 
tion with  septic  absorption  a  subnormal  temperature  is  frequently 
noted. 

Pulse. — In  acute  obstruction  the  pulse  is  quickly  and  profoundly 
affected.  It  becomes  exceedingly  rapid  and  weak,  thus  markedly 
contrasting  with  the  normal  or  subnormal  temperature.  Of  all 
single  symptoms  this  is  the  one  which  is  most  constant  and  most 
significant  as  to  the  vital  condition  of  the  patient.  As  a  means  of 
differential  diagnosis  it  is  of  no  value. 

Meteorism  and  abdominal  configuration. — If  the  patient  is  seen 
early,  the  meteorism  may  suggest  the  seat,  if  not  the  nature,  of  the 
obstruction.  With  a  stojipage  at  the  sigmoid  flexure,  first  the  colon, 
then  ultimately  the  small  intestines  become  distended,  giving  the 
belly  a  quadrilateral  shape.  When  the  small  intestines  are  involved 
there  is  primarily  a  bullet-shaped  enlargement  of  the  central  part  of 
the  belly,  with  flatness  in  the  region  of  the  colon.  The  amount  of 
distention  is  dependent  upon  the  absoluteness  of  the  obstruction, 
the  presence  or  absence  of  vigorous  peristalsis,  and  the  amount  of 
fermentable  matter  in  the  bowel.  So  long  as  the  muscular  walls 
of  the  gut  retain  vigorous  contracting  power,  there  is  constant  re- 
gurgitation of  liquids  and  gases  into  the  stomach,  whence  they  are 
quickly  vomited.  When  paralysis  allows  wade  dilatation  and  con- 
sequent kinking,  the  contents  of  the  gut  cannot  escape,  and  meteor- 
ism reaches  its  extreme  limit. 

An  irregularity  in  the  abdominal  distention  is  of  diagnostic 
value ;  in  both  volvulus  and  strangulation  the  constricted  loop  is 
the  first  to  become  inflated ;  this  loop,  if  of  any  length,  Avill  pro- 
duce a  local  tumefaction  preceding  the  general  swelling.  Invagi- 
nation usually  gives  but  little  meteorism.  In  general,  the  distention 
is  proportionate  to  the  suddenness  and  acuteness  of  the  process. 

Peristalsis. — This,  in  peritonitis  and  paralysis  of  the  bowel  from 
other  causes,  is  absent.  In  mechanical  obstruction  it  is  violent  and 
long  continued,  and  can  be  perceived  by  palpation  and  auscultation. 

Urine. — Though  much  has  been  written  upon  this  subject,  there 
is  little  here  to  guide  us.  In  amount,  it  probably  depends  upon  the 
frequency  of  vomiting.  In  strangulation  it  has  often  been  observed 
to  contain  albumin,  while  in  pure  obstruction  iudican  in  large 
quantities  is  always  found.     We  have  made  a  number  of  personal 


84  WOUNDS    AND    OBSTRUCTION    OF   THE    INTESTINES, 

observatious  upon  this  test,  but  find  indioan  so  frequently  present 
in  other  pathok)gical  conditions,  or  even  Avhen  tlie  urine  is  in  all 
respects  normal,  that  the  finding  of  it  in  any  given  case  is  without 
value. 

Vomiting. — In  strangulation,  vomiting  comes  on  early  and  be- 
comes fecal  rapidly.  In  other  forms  of  obstruction  the  vomiting 
may  be  slight,  or  even  wanting  altogether.  In  peritonitis  it  is 
bilious  and  at  times  takes  the  form  of  an  outpouring  from  the 
stomach  with  scarcely  any  eifort  on  the  part  of  the  patient,  and 
with  all  the  symptoms  of  a  cholera-collapse.  In  both  volvulus 
and  invagination  the  vomiting  is  rarely  fecal. 

Constipation. — Excepting  invagination,  there  is  constipation  in 
all  of  the  forms  of  obstruction.  Volvulus  sometimes  gives  one  or 
two  passages,  and  at  times  the  onset  of  peritonitis  is  denoted  by 
watery  alvine  evacuations. 

Tenesmus. — This  is  peculiarly  characteristic  of  intussusception 
involving  the  descending  colon  and  sigmoid  flexure,  thouo-h  it  has 
been  noted  in  volvulus  of  this  part  of  the  gut.  When  combined 
with  the  discharge  of  blood  and  mucus  it  practically  makes 
certain  the  diagnosis  of  intussusception. 

Palpation  and  i^ercussion  will  detect  the  tenderness  of  perito- 
nitis, the  sausage-shaped  erectile  tumor  of  intussusception,  the 
doughy  masses  of  fecal  impaction,  the  central  tympany  with 
peripheral  dulness  of  exudative  peritonitis,  the  hard  induration 
of  cancerous  stricture,  the  localized  tenderness  and  resistance  of 
circumscribed  jDcritonitis,  and  more  rarely,  the  tender  tympanitic 
swelling  of  strangulation  or  volvulus.  An  examination  of  the 
rectum  should  never  be  omitted,  since  invagination,  occlusion  by 
malignant  growth,  and  impaction  of  feces  or  foreign  body  have 
many  times  been  diagnosed  by  this  means. 

Auscultation. — The  loud  borborygmi  dependent  upon  the  increased 
peristalsis  of  mechanical  obstruction  are  readily  heard  ;  at  times  they 
can  be  traced  to  the  point  of  obstruction,  where  they  are  replaced, 
according  to  Auffret,  by  a  peculiar  click  resembling  that  of  the 
water-hammer.  By  using  gentle  palpation  the  friction  sounds  of  a 
beginning  peritonitis  may  occasionally  be  perceived. 

Injection. — Gas  or  water  can  be  used  and  either  will  be  of  diag- 
nostic value  in  the  early  stages  of  obstruction.  The  colon,  if  per- 
vious, can  by  this  means  be  clearly  outlined  and  percussed  ;  if  not, 


DIAGNOSING    VARIOUS    FORMS    OF    INTESTINAL   OBSTRUCTION.       85 

tlie  imiiossibility  of  forcing  over  a  quart  of  water  into  the  bo-\vel 
would  at  ouee  suggest  an  occlusion  about  the  sigmoid  flexure.  It 
must  be  borne  in  mind  that  the  amount  of  water  which  the  rectum 
can  hold  varies  greatly,  depending  upon  the  condition  of  its 
muscular  coat,  and  that  at  times  its  capacity  for  distention  is  very 
great. 

In  a  case  reported  by  Miller^  the  test  of  the  capacity  of  the 
rectum,  and  its  perviousuess  to  water  injection  seems  to  have  failed, 
since,  although  the  strangulation  was  in  the  small  intestine,  only  a 
very  small  amount  of  liquid  could  be  forced  into  the  bowel  by  the 
injection  pipe.  The  report  of  this  case  is  so  meagre,  however,  that 
it  is  impossible  to  discover  how  thorough  a  trial  was  made  of  the 
method. 

Prognosis. — It  is  almost  impossible  to  justly  decide  as  to  the 
average  chance  of  life  in  a  case  of  acute  intestinal  obstruction. 
On  the  one  hand  the  statement  is  made  that  "  nearly  all  cases  of 
acute  mechanical  intestinal  obstruction  die  unless  relieved  by  surgi- 
cal interference,"^  on  the  other  it  is  within  the  experience  of  every 
practising  physician  that  cases  of  this  nature  do  get  well  under 
careful  medical  treatment.  As  to  the  probability  of  relief  to 
internal  strangulation,  or  confirmed  volvulus  by  palliative  means 
this  is  open  to  doubt,  since  an  autopsy  is  necessary  to  confirm  the 
diagnosis,  but  that  paretic  distention  and  invagination  frequently 
yield  to  the  physician's  manipulations  cannot  be  questioned. 
Curschmann^  places  the  mortality  of  obstruction  from  all  causes  at 
about  65  per  cent.  Our  own  tables  give  a  considerably  higher 
death  rate. 

1  Edinburg  Med.  Jour.,  1890. 

2  Fitz.,  Boston  Med.  &  Surg.  Jour.,  Nov.  15,  1888. 

3  Therapeut.  Mouatsh.,  May,  1889. 


CHAPTEE  X. 

ON  THE  GENERAL  TREATMENT  OF  INTESTINAL  OBSTRUCTION. 

On  this  question  the  surgeon  and  physician  are  arrayed  against 
each  other.  The  extremist  of  one  party  rejects  all  the  ordinary 
therapeutical  agencies  and  advises  immediate  recourse  to  the  knife, 
while  his  opponent  cites  the  appalling  mortality  of  operative  cases, 
and  trusts  to  measures  which,  if  not  successful,  at  least  do  not 
hasten  death. 

In  so  far  as  statistics  can  be  relied  on,  the  surgeon  certainly  has 
the  best  of  the  discussion.  In  another  place  we  have  alluded  to 
some  of  the  reasons  which  make  conclusions  founded  upon  reported 
cases  of  doubtful  value.  Under  intussusception  it  has  been  shown 
that  the  mortality  of  the  operative  cases  was  practically  the  same 
as  that  of  cases  treated  expectantly,  although  as  a  rule  only  the 
desperate  cases  were  subjected  to  the  knife.  It  may  be  safely 
assumed  that  the  mortality  of  cases  of  acute  intestinal  obstruction 
treated  medically  lies  somewhere  between  65  and  75  per  cent.,  our 
own  statistics  give  73.2  per  cent.  Obalinski,^  of  38  cases  treated 
by  laparotomy  lost  60.5  per  cent.  In  his  last  series  of  nineteen 
the  mortality  was  52.6  per  cent.  Schramm  gives  a  mortality,  since 
the  aseptic  wound  treatment,  of  58  per  cent.  Curtis^  reports  328 
cases  of  acute  intestinal  obstruction  treated  by  section  with  a  mor- 
tality of  68.9  per  cent.,  62  cases  treated  by  enterostomy^  gave  a 
mortality  of  43.3  per  cent. 

Far  more  conclusive  than  statistics,  which  are  decidedly  favorable 
to  operation,  are  the  records  of  the  autopsy  room,  which  show  that 
so  many  of  the  fatal  cases  could  have  been  relieved  by  operation. 

It  is  now  very  generally  conceded  that,  provided  a  patient  is  in 
good  general  condition,  an  exploration  of  the  abdominal  cavity,  if 
quickly  performed,  is  attended  with  very  little  danger  to  life. 
When  tympany  is  enormously  developed  such  exploration  becomes 

1  V.  Langenbeck,  Arch.  f.  Chirur.,  xxxviii.  2. 

2  Annals  of  Surg.,  May,  1888.  3  Med.  Rec,  Sept.  1,  1888. 


GENERAL   TREATMENT    OF    INTESTINAL    OBSTRUCTION.         87 

both  difficult  and  dangerous;  where  the  case  is  complicated  by 
peritonitis  and  adhesions  the  surgeon  may  find  it  impossible  to 
discover  the  seat  of  obstruction.  Tliese  cases  then  present  in  their 
early  stages  no  grave  difficulties  to  the  surgeon,  eitlier  from  the 
mechanical  obstacles  to  be  overcome  or  from  the  unfavoral>]e  con- 
dition of  the  patient ;  in  the  latter  stages  complications  and  diffi- 
culties are  developed  which  may  well  deter  the  boldcsst  froni 
operating.  It  is  then  in  the  early  stages  that  operation  should  be 
advised.  All  surgeons  are  agreed  upon  this  point,  and  many 
physicians  are  realizing  its  importance. 

The  question  at  once  arises,  what  is  meant  by  the  early  stages  ? 
A  certain  amount  of  time  is  often  necessary  to  confirm  the  diagnosis. 
Vomiting,  constipation,  pain,  and  meteorism  may  be  symptomatic 
of  conditions  other  than  those  of  intestinal  obstruction.  It  is  upon 
the  persistence  of  these  symptoms  and  the  development  of  others 
that  the  surgeon  must  rely,  and  this  may  be  a  matter  of  hours,  or 
even  days.  Richardson^  considers  stercoraceous  vomiting  as  the 
index  of  obstruction  requiring  operation.  Since  this  symptom  is 
frequently  absent  even  in  acute  strangulation,  cases  running  a  fatal 
course  before  fecal  vomiting  has  time  to  appear,  this  sign  is  not  for 
a  moment  to  be  relied  on, 

Schramm  advises  immediate  operation  upon  the  diagnosis  of 
obstruction  being  confirmed.  In  the  discussion  of  the  British 
Medical  Association  upon  the  subject  (1887)  the  general  consensus 
of  opinion  seemed  to  be  that  in  doubtful  cases  no  time  should  be 
lost  but  an  exploratory  section  should  at  once  be  performed. 

Obaliuski  advises  in  acute  cases  that  an  exploratory  incision 
should  be  made  in  the  first  twenty-four  hours.  The  paralytic 
impermeability  following  typhlitis,  oophoritis,  or  other  forms  of 
local  peritonitis,  should,  however,  be  treated  expectantly.  Of 
twelve  such  cases  subjected  by  Obalinski  to  morphia  and  bella- 
donna treatment,  nine  recovered. 

Goltdamer^  would  limit  laparotomy  to  cases  of  intussusception  ; 
cases  in  which  symptoms  of  obstruction  are  steadily  progressive  in 
spite  of  the  free  use  of  opium ;  cases  in  which  after  opium  has 
produced  a  remission  of  all  symptoms,  these  seem  suddenly  ta 
develop  anew. 

1  Med.  Press  and  Circ,  Feb.  7,  1889. 

2  Brit.  Med.  Jouru.,  March  11,  1889. 


88  WOUNDS    AND    OBSTRUCTION    OF    THE    INTESTINES. 

Kroiilein  and  Czerny  advise  early  oiJeration  ;  abdominal  section 
Avlien  the  strength  of  the  patient  is  well  ])reserved  ;  Avhen  the  abdo- 
men is  soft  and  not  distended ;  and  when  by  means  of  jialjiation 
the  seat  of  obstrnetion  ean  be  partly  "determined.  In  all  other 
oases  they  advise  an  ileostomy  through  a  small  incision. 

Both  surgeons  and  ])]iysicians  are  agreed  upon  the  value  of  opium 
in  cases  of  mechanical  obstruction.  It  is  best  given  in  the  foi'm  of 
morphia  subcutaneously,  and  should  be  combined  with  full  doses 
of  belladonna  or  its  alkaloid  atropia.  Of  the  effects  of  these  drugs 
we  have  spoken  under  peritonitis. 

We  feel  convinced  that  the  time  to  operate  cannot  be  expressed 
in  hours  or  days,  or  by  specific  symptoms.  It  is  first  necessary  to 
confirm  the  diagnosis  of  obstruction,  and  this  in  the  majority  of 
cases  is  quickly  and  surely  done.  Immediately,  morphia  and  bel- 
ladonna having  been  properly  administered  and  the  stomach  having 
been  washed  out,  one  thorough  trial  at  reduction  should  be  made. 
In  all  cases  the  patient  should  be  relaxed  by  the  administration  of 
an  anaesthetic.  If  invagination  is  suspected,  slow,  persistent  gravity 
injection  with  abdominal  kneading  or  inversion  and  shaking.  In 
supposed  volvulus  and  internal  strangulation  the  same  treatment 
with  the  patient  in  the  knee-elbow  position  can  do  little  harm.  In 
supposed  intestinal  paralysis  the  application  of  electricity. 

If  this  trial  is  unsuccessful  immediate  abdonjinal  section  is  indi- 
cated. 

At  this  stage,  when  the  patient's  strength  is  well  preserved,  when 
tympany  is  but  mildly  developed,  when  there  is  reason  to  believe 
that  no  extensive  pathological  changes  have  taken  place  in  the  gut, 
we  think  an  enterostomy  as  a  primary  procedure  should  not  be 
considered.  The  abdomen  should  be  opened  by  a  free  median 
incision,  and  the  ordinary  seats  of  obstruction  should  be  explored 
by  eye  and  hand. 

Since  the  fatal  result  after  abdominal  section  is  commonly  due  to 
shock,  the  operation  should  be  conducted  with  the  greatest  possible 
rapidity.  If  the  seat  of  obstruction  cannot  be  quickly  found ;  or 
if  found  required  a  tedious  procedure  for  the  restoration  of  the  con- 
tinuity of  the  gut,  we  think  an  enterostomy  would  be  indicated. 

Circular  enterorraphy  has  in  these  cases  been  nearly  uniformly 
fatal.  Ijateral  approximation  by  plates  or  implantation,  or  invagi- 
nation by  the  rubber  ring  are  quickly  performed,  and  when  the 


GENERAL   TREATMENT   OF    INTESTINAL    OBSTRUCTION.         89 

operation  lias  not  already  been  unduly  prolonged,  may  be  indieated. 
A  half  hour  should,  in  gciueral,  be  the  extreme  limit  of  time  during 
Avhieh  the  belly  should  be  open.  If  this  period  has  elapsed,  and 
the  seat  of  trouble  is  not  yet  found,  or  if  found  the  obstruction  not 
overcome,  an  enterostomy  shoidd  be  performed. 

Under  some  circumstances  the  seat  of  obstruction,  when  not 
acutely  congested  or  influmed,  may  be  switched  out  of  the  ali- 
mentary tract  by  an  anastomosis  between  the  afferent  and  efferent 
bowel  segments.  In  general  the  operator  should  aim  at  rapidity 
of  manipulation  and  the  immediate  safety  of  the  patient,  rather 
than  at  an  ideal  restoration  of  parts  to  their  normal  condition. 

We  think  that  the  danger  of  secondary  occlusion  by  displace- 
ment of  bowel  segments  or  by  intestinal  paralysis  is  lessened  by  an 
abundant  irrigation  of  the  peritoneal  cavity  with  hot  saline  solution. 
Malcolm^  has  called  attention  to  the  value  of  this  as  a  means  of 
securing  a  natural  disposition  of  the  intestines  after  abdominal 
section. 

The  preservation  of  the  body  heat  of  the  patient  is  most 
important.  The  operating  table  we  describe,  together  with  thin 
ribbed  hot  water  bags  placed  over  the  chest  and  about  the  portion 
of  the  abdomen  which  is  not  subject  to  operation,  are  efficient 
means  of  accomplishing  this.  Since  the  amount  of  heat  abstracted 
from  the  highly  vascular  peritoneum  is,  when  the  latter  is  exposed, 
enormous,  it  should  be  the  duty  of  one  assistant  to  keep  all  exposed 
bowel  segments  covered  with  rubber  dam  or  with  thin  sponges 
wrung  out  in  hot  saline  solution. 

Nothing  should  be  taken  by  the  mouth  for  from  twenty-four  to 
forty-eight  hours  after  operation. 

1  Lancet,  Jan.  11,  1890. 


CHAPTER  XI. 

SPECIAL,   TREATMENT    OF   OBSTRUCTION. 

In  a  detailed  consideration  of  the  various  methods  of  treatment 
advocated  for  intestinal  obstruction,  including  the  surgical  opera- 
tions which  are  indicated,  the  first  subjects  which  present  them- 
selves are — 

Diet  and  medication. — The  profession  is  now  practically  unani- 
mous in  advising  that  neither  food  nor  drink  should  be  given  by 
the  mouth  during  the  continuance  of  acute  obstructive  symptoms. 
The  objection  to  gastric  alimentation  is  not  merely  that  there  can 
be  no  digestion  and  no  absorption,  but  that  fresh  matter  is  supplied 
for  decomposition,  and  that  fresh  impetus  is  given  to  the  exhausting 
vomiting.  In  one  unreported  case  of  acute  obstruction  we  withheld 
f(jod  for  six  days  ;  the  patient  recovered  showing  no  marked  emacia- 
tion as  a  result  of  her  long  fast.  There  can  be  no  objection  to  the 
administration  by  the  rectum  of  beef  peptoids  of  peptonized  milk 
and  eggs,  and  of  stimulants.  The  thirst  is  relieved  by  gently 
injecting  one  or  two  pints  of  warm  water  into  the  lower  bowel. 

If  the  heart  shows  signs  of  flagging,  especially  if  there  is  a 
condition  of  collapse  similar  to  that  observed  in  cholera,  three  to 
six  ounces  of  whiskey  dissolved  in  one  to  two  pints  of  warm  saline 
solution  can  be  thrown  by  gravity  into  the  cellular  tissues. 
Hypodermics  of  ether,  frequently  repeated,  are  peculiarly  applica- 
ble to  this  condition.  Personally  we  have  not  obtained  satisfactory 
results  from  the  use  of  digitalis.  Against  heart  failure,  whiskey 
is  the  main  stay,  and  must  be  pushed  to  its  physiological  effect. 
The  rectum  may  also  be  used  for  the  absorption  of  whiskey,  but  in 
this  case  it  should  be  diluted  at  least  six  or  eight  times  since  acute 
inflammation  of  the  mucous  membrane  has  been  produced  by  con- 
centrated solutions. 

Of  opium  and  belladonna,  the  two  drugs  mainly  indicated,  we 
have  spoken  at  length  under  peritonitis.  AVe  think  that  both 
should  be  given  hypodermically. 


SPECIAL    TREATMENT    OF    OBSTRUCTION.  91 

Strychnia  is  at  times  of  g;rcat  service,  especially  in  conditions  of 
profound  nervous  shock,  and  in  paretic  states  of  the  bowel.  To  be 
of  service  it  must  be  pushed  till  its  physiological  effect  is  produced. 

Purgatives  are  to  be  avoided,  Stoker'  being  the  only  surgeon  of 
prominence  advocating  their  use  in  recent  times. 

Lavage  of  the  stomach. — This  treatment,  originally  advocated  by 
Klissmaul,  has  received  the  highest  clinical  endorsement.  Its  effect 
is  direct  and  readily  understood.  It  mechanically  removes  a  large 
quantity  of  putrid  septic  matter  which  otherwise  would  be  slowly 
and  laboriously  regurgitated  by  violent  muscular  efforts,  thus  still 
further  weakening  an  already  debilitated  patient.  It  assists  nature 
in  her  eliminative  efforts,  and  almost  without  exception  produces 
an  immediate  improvement  in  the  patient's  condition.  Indeed, 
there  is  so  great  an  amelioration  of  symptoms  that  this  procedure 
is  utterly  condemned  by  some  surgeons  as  producing,  like  opium,  a 
seeming  improvement  not  warranted  by  the  condition  of  the  bowel 
at  the  seat  of  obstruction,  and  thus  leading  to  a  postponement  of 
operation. 

In  some  cases  it  produces  not  only  relief,  but  is  absolutely  cura- 
tive. Mahnert^  reports  several  cases  of  cure.  Even  where  death 
is  inevitable  it  is  productive  of  such  relief  that  it  may  be  employed 
if  nausea  and  vomiting  are  well  marked.  Curschmann^  ranks 
M'ashing  of  the  stomach  next  to  opium  as  a  palliative  and  curative 
agent.  NothnageP  and  Gerster^  commend  this  procedure,  as  do 
indeed  all  surgeons  who  have  fairly  tried  it. 

Either  plain  water  may  be  used,  or  normal  saline  solution,  or 
mild  antiseptic  lotions,  such  as  solutions  of  boric  or  salicylic  acid. 
Since  there  is  a  patulous  condition  of  the  pylorus  the  weak  anti- 
septic solutions  are  particularly  indicated,  as  by  becoming  mingled 
with  the  intestinal  contents,  further  fermentation  is  retarded  or 
entirely  prevented.  We  believe  that  these  injections  should  always 
be  made  with  hot  solutions  (106°  F.)  for  reasons  given  under  the 
section  on  enemata. 

Enemata. — In  the  use  of  enemata  there  is  more  confidence  than 

1  Dublin  Jonrn.  Med.  Sc,  Nov.  1889. 

2  Memorabil.  Heil.,  March  16,  1889. 

3  Therapeut.  Monatsli.,  May,  1889. 

*  AUgemein.  Wien.  Med.  Zeit.,  Maj  7, 1889. 
5  N.  Y.  Med.  Jonrn.,  May,  1889. 


92  WOUNDS    AND    OBSTRUCTION    OF    THE    INTESTINES. 

in  all  the  combined  palliative  means  of  treatment.  Though 
peeuliarly  applicable  to  cases  of  intussusceptiou,  paralysis  is  bene- 
fited by  the  stimulus  thus  given  to  peristalsis.  It  is  asserted  that 
volvulus  may  be  untwisted  provided  the  injection  is  accompanied 
by  inversion  or  massage,  and  even  internal  strangulation  may  be 
made  to  yield  to  the  gradual  distention  of  the  lower  bowel  segment, 
though  clinical  proof  in  regard  to  the  justice  of  these  claims  is 
Avanting. 

In  the  chronic  obstructions  dependent  upon  impacted  feces  and 
upon  narrowing  in  some  portion  of  the  colon  the  use  of  enemata  is 
practically  the  only  palliative  measure  left  to  the  physician. 

The  method  of  giving  enemata  has  been  described  under  invagi- 
nation. 

Even  though  the  invagination  were  seated  at  the  small  bowel  we 
would  not  hesitate  to  employ  injection  as  described.  Seun  states, 
on  the  basis  of  experiments  resulting  fatally  upon  animals,  "  That 
the  injection  of  the  water  beyond  the  csecal  valve,  in  the  treatment  of 
intestinal  obstruction,  must  be  looked  upon  in  the  light  of  a  danger- 
ous expedient,  and  must  never  be  resorted  to."  We  have  repeat- 
edly passed  water  from  the  anus  to  the  mouth  of  dogs  without 
producing  the  slightest  unfavorable  symptoms,  except  in  one  in- 
stance, our  first  experiment,  where  water  was  taken  directly  from 
the  tap  (52°  F.) ;  the  dog  perished  after  twelve  hours,  having  suf- 
fered with  tenesmus,  and  having  passed  some  blood-stained  mucous 
evacuations.  The  post-mortem  examination  showed  intense  coii- 
gestion  of  the  colon. 

Battey^  reports  a  case  in  which  water  injected  into  the  anus  with 
an  ordinary  syringe  entered  the  stomach  and  was  vomited. 

Though  the  necessity  for  injections  so  copious  as  this  rarely  arises, 
yet  there  are  scattered  through  medical  literature  a  sufficient  num- 
ber of  reports  to  confirm  the  results  of  our  experiments  upon  dogs 
as  to  the  harmlessness  of  forcing  water  past  the  ileocsecal  valve. 

There  are  certain  points  of  cardinal  importance  to  be  considered 
in  making  these  injections  : — 

1.  The  liquid  must  enter  the  bowel  by  a  gradual,  steady  floAV. 

2.  The  temperature  should  not  differ  greatly  from  that  of  the 
body. 

Atlanta  Med.  and  Surg.  Journ.,  June,  1874.     Medical  Record,  July  1,  1S74. 


SPECIAL   TREATMENT   OF   OBSTRUCTION.  93 

3.  The  pressure  should  be  uniform  and  long-continued,  starting 
at  two  pounds  (an  elevation  of  4  feet),  and,  if  necessary,  gradually 
increasing  to  not  over  eight  pounds  (elevation  of  16  feet),  this  is 
effected  by  slowly  raising  the  reservoir. 

4.  Not  over  three-quarters  of  an  hour  should  be  spent  in 
attempting  to  force  the  liquid  past  the  seat  of  constriction. 

The  danger  of  rupturing  the  bowel  must  not  be  forgotten.  In 
any  case  where  beginning  mortification  is  feared,  as,  for  instance, 
in  intussusception  where  shreds  of  necrotic  tissue  have  been  dis- 
charged, or  in  cases  characterized  by  acute  symptoms  which  have 
lasted  for  three  days  or  upwards,  we  think  that  the  danger  of 
forced  injection  is  so  great,  and  its  probable  efficacy  so  limited, 
that  it  should  give  place  to  operative  procedure. 

We  have  knowledge  of  three  unreported  cases  in  which  forced 
injections  resulted  in  rupture  of  the  bowel  and  speedy  death.  In 
each  case  these  injections  were  made  with  the  Davidson  syringe,  and 
the  amount  of  force  used  was  undeterminable.  There  are  many 
recorded  cases  where  this  accident  has  occurred.'  Under  any  cir- 
cumstances there  is  a  risk  in  the  employment  of  eight  pounds  of 
pressure,  though  experiment  has  shown  us  that  this  is  far  within 
the  bursting  strain  of  normal  gut.  In  view  of  the  hundreds  of 
successful  results  following  this  method,  or  rather  very  imperfect 
attempts  at  it,  we  think  the  physician  is  justified  in  taking  this 
risk  in  suitable  cases,  provided  preparation  is  made  for  an  iinmedi- 
ate  abdominal  section,  should  symptoms  characteristic  of  rupture 
of  the  bowel  appear  (t.  e.,  sudden  uniform  swelling  of  the  belly, 
loss  of  outline  of  distended  colon,  and  collapse). 

We  would  particularly  protest  against  frequently  repeated  small 
injections  with  the  Davidson  or  other  pumping  syringe. 

Each  hour  diminishes  the  chances  of  success.  That  second  and 
third  efforts  have  accomplished  their  objects  has  been  simply  be- 
cause they  were  more  efficiently  made.  At  the  first  effort  the  cir- 
cumstances are  most  favorable  for  reduction,  and  the  physician  is 
justified  in  using  more  force  and  perseverance  than  at  any  other  time 
in  the  course  of  the  disease.  This  first  attempt  should,  then,  be  so 
thorough  that  he  can  feel  assured  the  method,  and  not  its  mode  of 
application,  is  at  fault. 

1  Medico-Cliirurgical  Trausactions,  59th  volume. 


94  WOUNDS    AND   OBSTRUCTION   OF   THE    INTESTINES. 

Electricity. — As  a  means  of  encouraging  peristalsis,  electricity 
has  been  warmly  commended  from  the  time  of  its  general  intro- 
duction into  the  treatment  of  disease.  How  it  can  effect  the  me- 
chanical forms  of  obstruction  is  difficult  to  understand,  yet  many 
cases  of  cure  are  j)laced  to  its  credit.  It  is  in  paralytic  distention, 
however,  that  this  treatment  has  obtained  most  brilliant  results. 

As  a  type  of  the  results  sometimes  obtained  we  quote  one  case, 
given  together  with  several  others  by  Auffret.^  The  patient  had  a 
history  of  previous  slight  attacks  of  a  similar  nature ;  after  sev- 
eral days  of  constipation  he  entered  the  hospital  with  great  abdom- 
inal pain  exaggerated  by  pressure,  with  meteorism  and  bilious 
vomiting. 

Abdominal  facies  was  marked,  the  thighs  were  flexed  upon  the 
body,  the  pain  was  located  about  the  umbilicus,  there  was  general 
meteorism,  with  dilated  intestinal  loops  clearly  outlined  through 
the  parietes.     Pulse  scarcely  perceptible ;  temperature  subnormal. 

The  following  day  all  symptoms  were  exaggerated,  and  death 
seemed  immediate  and  inevitable. 

The  two  poles  of  a  faradic  battery  w^ere  placed  one  over  the  ab- 
dominal parietes,  the  other  within  the  rectum.  The  application 
w^as  continued  twenty  minutes,  and  was  carried  to  its  maximmn 
intensity,  when  suddenly  the  patient  experienced  a  sudden  jar 
accompanied  by  a  feeling  of  intestinal  displacement.  Immediately 
free  evacuation  of  gas  and  fecal  masses  took  place  through  the 
bowel,  and  the  patient  rapidly  convalesced. 

In  one  of  our  cases  the  application  of  faradism  was  equally  suc- 
cessful. A  patient  suffering  from  chronic  Bright's  disease  remained 
obstinately  constipated  for  three  days,  when  the  abdomen  became, 
rather  suddenly,  enormously  distended ;  the  patient  complained  of 
intense  pain  about  the  umbilicus,  and  frequently  repeated  bilious 
vomiting  set  in.  In  eight  hours  the  distention  had  reached  such 
a  degree  that  death  from  respiratory  failure  was  threatened.  The 
rectal  tube,  stimulating  enemata,  large  forced  enemata  had  all  been 
tried  in  vain. 

Before  resorting  to  puncture  of  the  bowel  the  poles  of  a  powerful 
faradic  battery  were  applied,  one  to  the  small  of  the  back,  the  other 
to  the  abdominal  muscles.     In  fifteen  minutes  there  was  an  enor- 

1  Mem.  sur  les  Occlus.  Intest.,  Par.,  1885. 


SPECIAL,   TREATMENT    OF   OBSTRUCTION.  95 

moiis  discharge  of  gas  followed  by  several  passages  of  tliin  yellow 
feces. 

Both  these  cases  were  probably  examples  of  paralytic  obstruc- 
tion. Where  it  is  imeertain  whether  this  condition  or  mechanical 
blocking  is  causing  obstructive  symptoms  we  think  the  application 
of  the  faradic  battery  should  be  given  a  thorough  trial,  preferably 
by  a  metal  electrode  carried  into  the  rectum  the  other  pole  being 
applied  to  the  belly  walls.  As  a  means  of  applying  the  current 
still  more  directly,  Heard*  advocates  filling  the  rectum  with  saline 
solution  and  introducing  the  rectal  electrode  into  this. 

Perhaps  the  majority  of  physicians  utterly  distrust  electricity  as 
a  curative  agent  in  intestinal  obstruction.  This  is  doubtless  owing 
to  its  want  of  success  in  cases  dependent  upon  mechanical  causes. 
Even  that  the  majority  of  paralytic  obstruction  cases  Avill  yield  to 
its  influence  cannot  be  claimed.  That  some  do,  is  indisputable,  and 
we  think  that  an  agent  which  may  do  good,  which  consumes  little 
time  in  its  application,  and  which,  if  unsuccessful,  can  do  no  harm, 
should  be  given  a  fair  trial. 

Gaseous  injection. — The  injection  of  air  or  gas  as  a  means  of 
locating  intestinal  obstruction  has  lately  been  warmly  and  nearly 
universally  commended.  Belief  in  its  greater  permeability  is 
universal,  the  experiments  of  Senn,  and  the  statements  of  Cursch- 
mann^  and  the  majority  of  surgeons  being  to  the  effect  that  the 
ileocsecal  valve  is  practically  closed  to  the  upward  passage  of 
water.  Malmert,^  Damsch,^  Head,^  Crisp,^  Bryant,^  and  many 
others  have  employed  air  injections  in  the  treatment  of  intussus- 
ception. Schuetter  advocates  COg,  and  Damsch  states  that  a  litre 
of  this  will  fill  the  colon  to  the  ileocsecal  valve  without  producing 
peristalsis,  but  that  it  will  not  pass  this  valve  as  readily  as  will  air. 

That  air  or  gas  injections  have  frequently  been  efficient  in 
removing  the  cause  of  obstruction  cannot  be  denied,  but  as  the 
pressure  is  less  directly  under  control,  and  as  in  certain  cases,  the 
mechanical  benefit  of  the  weight  of  water  seems  to  be  an  important 

1  Weekly  Med.  Eev.,  Aug.  17,  1889. 

2  Log.  cit.  ^  Lqc.  cit. 
*  Berlin.  Klin.  Woch.,  April  15,  1889. 

5  St.  Barthol.  IIosp.  Kept.,  1867,  III.  85. 

^  London  Lancet,  1847,  I.  557. 

'  Brit.  Med.  Journ.,  1884,  II.  1801. 


96  AVOUNDS    AND    OBSTRUCTION    OF   THE    INTESTINES. 

factor  iu  tlie  accomplishment  of  a  cure  we  do  not  consider  insuffla- 
tion so  valuable  a  method  of  treatment  as  injection  of  liquids. 

We  performed  numerous  experiments  upon  dogs,  injecting  air 
from  end  to  end,*  and  in  one  instance  ligating  the  cardiac  end  of 
the  stomach  and  injecting,  with  the  idea  of  discovering  how  readily 
intestinal  paralysis  from  over-distention,  and  consequent  crippling 
of  the  diaphragm  could  be  accomplished.  A  pressure  of  foiu- 
pounds  was  as  much  as  we  could  obtain  with  the  means  at  hand, 
and  this  continued  for  three-quarters  of  an  hour,  produced  but 
little  more  distention  than  that  present  when  the  gas  was  freely 
eructated. 

This  proved  that  the  effect  upon  respiration  and  circulation  was 
absolutely  negative  in  gaseous  injections  even  when  an  obstruction 
in  the  upper  part  of  the  alimentary  canal  was  present. 

The  cause  of  frequent  failure  of  this  method  is,  as  in  the  em- 
ployment of  enemata,  because  of  an  imperfect  method  of  applying 
it.  Any  injection  into  the  bowel  causes  a  spasmodic  resistance  and 
effort  at  extrusion — this  is  increased  if  the  pressure  is  constantly 
varying.  Spasm  ultimately  yields  to  steady  continued  pressure, 
even  though  this  be  very  slight.  Time  and  again  we  have  seen 
operators  fail  to  pass  gas  from  anus  to  mouth  simply  because  they 
did  not  recognize  the  importance  of  the  element  of  time  in  over- 
coming muscular  resistance.  The  spasmodically  contracted  muscles 
of  a  fractured  thigh,  which  even  the  mighty  po^ver  of  windlass  and 
pulley  may  fail  to  overcome,  yield  in  a  night  to  the  continued 
traction  of  a  few  pounds.  So  the  resistant  muscular  coat  of  the 
bowel  may,  if  the  struggle  be  short  and  violent,  rupture  before 
yielding,  but  inevitably  relaxes  under  persistent  gentle  pressure. 

1  As  a  type  of  this  series  of  experiments  the  following  is  given  : — 

Pup,  30  lbs.  purged  by  buck-thorn  the  night  before.  Two  grains  of  morphia 
administered  hypodermically. 

2.  P.M.  InsuiBation  begun  by  means  of  gas  bag.  Pressure  one  and  a  half 
pounds,  circumference  of  belly  13^  inches. 

2.10.  Circumference  of  belly  14  inches.  Colon  full  as  denoted  by  palpation 
and  percussion. 

2.15.  Loud  rumbling  and  rapid  inward  passage  of  gas  denoting  opening  of 
ileocecal  valve  ;  circumference  of  belly  16  inches. 

2.20.  Loud  rumbling  repeated,  denoting  entrance  of  gas  into  stomach,  cir- 
cumference of  belly  17  inches. 

2.23.  Gas  belched  up  at  intervals  of  a  few  seconds,  loud  rumbling  accom- 
panying each  eruction. 


SPECIAL  TREATMENT   OF  OBSTRUCTION.  97 

Thus  with  a  pressure  of  a  half  pound  we  have,  in  forty  minutes, 
passed  gas  along  the  entire  intestinal  tract  of  a  dog.  If  obstruction 
is  to  be  overcome,  the  gas  must  reach  the  seat  of  obstruction,  and 
it  is  far  safer  to  accomplish  this  by  moderate  continued  pressure, 
continued  for  thirty  or  forty  minutes,  than  by  rapidly  increasing 
the  pressure,  if  in  five  or  ten  minutes  no  results  seem  to  follow. 
The  physician  should  always  have  an  accurate  idea  of  just  how 
much  pressure  is  being  employed,  and  for  this  purpose  should 
attach  a  mercury  manometer  to  the  injection  pipe.  That  this  is  a 
necessary  precaution  is  shown  by  repeated  cases  of  rupture  during 
insufflation.^ 

Our  conclusions  in  regard  to  insufflation  are : — 

1.  It  is  a  valuable  means  of  overcoming  acute  obstruction  in  any 
part  of  the  alimentary  tract,  but  must  rank  in  order  of  efficiency 
after  water  injections. 

2.  The  injection  should  be  slow  and  long  continued,  the  pres- 
sure should  be  evenly  maintained  and  shoidd  be  indicated  by  a 
manometer. 

3.  The  danger  of  rupture  must  be  considered  in  gaseous  injec- 
tions. ' 

It   seems   proper    in   this   connection   to    discuss   two    subjects 
intimately  connected  with  rectal  injection,  namely  : — 
Heat  preservation,  and 

The  effect  of  intra-abdominal  pressure  produced  by  forced 
enemata. 

At  the  very  first  glance  it  will  be  clearly  seen  that  the  mainte- 
nance of  bodily  heat  at  the  normal  point  or  at  least  at  a  temperature 
approximating  the  normal  is  necessary  for  the  welfare  of  the  patient. 
This  is  very  well  illustrated  by  the  experiments  of  Brunton,  and 
many  others  including  our  own,  for  it  was  found  that  lethal  doses 
of  chloral  do  not  produce  death  if  the  bodily  heat  of  the  drugged 
animal  be  carefully  watched  after.  The  maintenance  of  the  normal 
temperature  in  man  is  far  more  important  than  its  maintenance  in 
animals.  In  the  human  body  every  atom  of  protoplasm  is  a 
sensitive  tropical  plant,  only  exposed,  except  in  disease,  to  the 
variation  of  a  very  small  fraction  of  a  degree  in  the  heat  supplied 

1  Medico-Chirurgical  Trans.,  1876,  p.  97. 


98  WOUNDS   AND   OBSTRUCTION   OF   THE   INTESTINES. 

to  it,  simply  because  man's  temperature  is  constant,  whereas  in  tlie 
dog  or  other  brute  the  normal  temperature  is  ever  varying,  now 
high,  now  lo^\'.  Thus  in  the  dog,  the  temperature  of  12  noon  may 
be  102.1°-;  at  12.15,  102.5°;  at  12.30  or  12.45,  102°,  and  by  2 
o'clock  np  to  103°,  only  to  return  at  3  to  the  original  number  of 
degrees,  and  }'et  perfect  health  be  present.  To  express  the  differ- 
ence in  a  homely  simile,  man  is  a  fine  chronometer,  never  varying, 
while  the  dog  or  rabbit  is  a  Waterbury  watch  made  of  cheap  and 
coarse  protoplasm  which  can  only  approximate. 

We  learn  therefore,  as  one  of  the  first  and  most  important  points 
in  the  use  of  injections  in  obstruction,  that  the  water  used  must  be 
warm,  and  that  cold  water  is  distinctly  harmful.  If  we  remember 
that  the  heat  functions  of  the  body  are  chiefly  centred  in  the  ab- 
dominal viscera,  and  that  these  viscera  are  particularly  arranged 
by  nature  in  such  a  way  as  to  be  protected  from  exposure  to  cold, 
we  can  readily  see  the  importance  of  this  subject.  For  the  pur- 
pose of  avoiding  chilling,  the  skin,  soft  tissues,  and  bones,  are 
arranged  as  one  impenetrable,  non-conducting  covering  which 
neither  transmits  cold  nor  heat.  Yet  some  have  resorted  to  cold 
injections  without  so  much  as  a  thought  that  the  patient,  already 
weakened  and  exhausted  by  disease  and  vomiting,  should  be  care- 
fully protected  from  cold,  particularly  in  his  vital  parts. 

For  the  purpose  of  determining  the  exact  importance  of  these 
precautions,  we  have  made  a  series  of  experiments  Avith  results 
which  are  well  shown  in  the  record  given  below  and  which  is  taken 
as  a  typical  example  of  a  number  of  trials.  It  will  be  seen  that 
the  introduction  of  water  as  it  comes  from  the  tap  lowers  the 
normal  bodily  heat  with  great  rapidity,  and  even  causes  marked 
coldness  of  the  belly  walls. ^ 

Experiment. — Dog,  weight  27  pounds.  No  morphine  or  ether 
used. 

11  A.  M.  Began  injecting  by  hydrostatic  syringe  four  quarts 
of  water  at  65°  Falir.,  the  pressure  being  equal  to  35 
millimeters  of  mercury.     Temperature  in  the  axilla  102°. 

1  The  method  of  experimentation  consisted  in  the  connection  of  an  ordinary 
fountain  syringe  with  a  Y-shaped  tube,  one  arm  of  which  was  attached  to  a 
mercurial  manometer,  the  other  to  the  tube  entering  the  rectum  of  the  animal. 
By  raising  and  lowering  the  bag  holding  the  water  the  pressure  could  be  varied 
at  will  and  the  manometer  afforded  a  ready  gauge  as  to  the  amount  of  this 
pressure. 


Tracings  to  determine  the  effect  of  passing  water  at  65°  F.  from  anus  to  mouth 
upon  the  pulse  and  respiration. 


[To  face  page  9St. 


Isy^^^y^-.-.r-'J^'-j^ 


II. 


jv/v\A/\^yV 


A/VnAJV^^ 


The  last  tracings  before  the  change  induced  lyy  vomiting  movements  shows  18  ram, 
fall  in  blood  pressure. 


SPECIAL   TREATMENT   OF    OBBTRUCTION.  99 

11.10  A.  M.  Belly  walls  are  exceedingly  cold,  frequent  rigors 

pass  over  the  body. 
11.30  A.  M.  Vomited  contents  of  stomach  and  the  water  which 
had   been  passed  through.     Axillary  temperature   now 
found  to  be  99°  Fahr.,  or  in  other  words  a  fall  of  3° 
in  bodily  temperature  had  taken  place  in  about  thirty 
minutes.     Temperature  of  the  internal  viscera  must  have 
been  even  less  than  this  owing  to  the  direct  contact  of  the 
water,  for  the  dog  was  in  a  state  of  collapse  and  shock, 
and  seemed  almost  dead  from  the  cold.     The  time  occu- 
pied in  passing  the  water  from  anus  to  mouth  was  thirty 
minutes,  the  pressure  being  35  millimetres.     [See  trac- 
ings.] 
Very  few  persons,  even  among  surgeons,  who  constantly  ope- 
rate, have  any  conception  of  the  decidedly  depressant  effects  which 
anaesthetics  exert  upon  bodily  temperature ;  and  again,  very  few 
know  that  the  mere  stretching  out  of  the  patient  upon  an  opera- 
ting table  also  produces  a  great  loss  of  heat.     The  following  experi- 
ments performed  by  us  in  regard  to  this  point  show  in  a  somewhat 
startling  but  nevertheless  accurate  manner  the  truth  of  our  asser- 
tions, and  w^e  have  found  them  to  hold  good,  not  only  in  the 
lower  animals,  but  also  in  man.     Thus  we  have  experimentally 
determined  that  it  is  possible  to  lower  the  normal  rectal  tempera- 
ture of  the  dog  as  much  as  from  8°  to  10°  Fahr.  by  continuous 
etherization  for  an  hour,  giving  two  drachms  of  ether  every  five 
minutes  after  the  animal  has  been  put  thoroughly  under  the  anaes- 
thetic influence. 

These  two  series  of  studies  on  man  Mdiich  follow  are  particularly 
interesting.  In  the  first  series  the  temperature  w^as  taken  in  the 
axilla,  and  in  the  second  in  the  rectum. 


100 


WOUXDS    AXD    OBSTRUCTION    OF    THE    INTESTINES. 


Series  I. 


No. 

Ojieratioii. 

Temperature  before. 

Temperature  after. 

1 

Anal  fistula    .... 

99° 

96.2° 

2 

Carcinoma       .... 

98.6 

95 

3 

Arthritis  of  knee    . 

99.1 

96  4 

4 

Arthritis  of  knee    .      ■  . 

98.8 

95.8 

5 

Sarcoma  of  both  testicles 

98.6 

94.2 

6 

Vesical  stone 

99 

97.1 

7 

Arthritis  of  knee     . 

99 

96.8 

8 

Vesical  stone 

98.6 

96.4 

9 

Traumatic  epilepsy 

98.1 

95.4 

10 

Necrosis  of  tibia 

98.5 

97.2 

11 

Necrosis  of  phalanx 

98.2 

96.8 

12 

Renal  calculus 

99.4 

96.8 

13 

Nasal  sarcoma 

98.4 

97.2 

The  average  fall  of  temperature  is  seen  to  be  over  2|°  Fahr., 
the  greatest  fall  being  4.4°  Fahr.,  the  least  1.2°. 


Series  II. 


No. 

Sex. 

Operation. 

Temperature 
before. 

Temperature 
after. 

Duration 
of  etheri- 
zation. 

1 

Adult,  M. 

Necrosis  of  femur     . 

99.5° 

98° 

If  hours. 

2 

Adult,  F. 

Carcinoma  of  axillary 

glands      .... 

100.15 

9S.5 

1  hour. 

3 

Adult,  M. 

Excision  of  the  knee 

Mouth,  99.4 

Mouth,  97.2 

Short. 

4 

Adult,  F. 

Abscess  of  abdominal 

wall 

99.4 

98.4 

1  hour. 

5 

Adult,  F. 

Caries  of  vertebrse    . 

Axillary.  98.4 

Axillary,  97 

1      " 

6 

Adult,  F. 

Carcinoma  of  breast 

99.45 

96.3 

I      " 

7 

Adult,  F. 

Carcinoma  of  breast 

98 

95.4 

3          U 

4 

8 

Adult,  M. 

Hypospadias  .     .     . 

99.2 

96.3 

9 

M.,  £et.  6 

McEwen's,    for    de- 

months. 

formity  of  tibia 

99.2 

97.4 

i         " 

10 

Adult,  M. 

Necrosis  of  femur     . 

Mouth,  98.4 

Mouth,  98.4 

k         " 

11 

Adult,  M. 

Epithelium   of    nose 

(plastic  operation) 

Axillary,  100.2 

Axillary,  99 

4 

12 

M. 

Excision  of  hip    .     . 

102 

100.2 

1          " 

13 

M. 

Empyema,  drainage- 

Avillnrv   f)S.4 

Axillary,  97.6 

k         " 

Average  fall  of  temperature  2.32°  F.  Greatest  fall  3.15°  Fahr. 
Smallest  Ml  0.8°  F. 

We  find  therefore  that  the  present  custom  of  applying  heat  to 
the  patient  is  closely  allied  to  locking  the  door  after  the  horse  is 
stolen,  and  the  results  given  in  these  two  tables  seem  at  least  to 


SPECIAL   TEEATMENT   OF    OBSTRUCTION.  101 

afford  siifificient  evidence  of  the  propriety  of  using  external  heat 
not  after,  but  during  anaesthesia. 

Since  the  placing  of  hot  cans  about  the  patient  during  operation 
is  not  practicable,  the  heating  apparatus  must  be  in  direct  coiuiec- 
tion  with  the  operating  table.  This  may  be  accomplished  by  means 
of  a  galvanized  iron  water  bath  made  in  the  form  of  a  shallow  tray, 
and  of  dimensions  sufficient  to  receive  the  patient. 

When  this  water  bath  is  placed  upon  an  operating  table  and 
filled  with  water  at  a  temperature  of  110°  there  is  no  danger  of 
burning  the  operator,  his  assistants,  or  the  patient,  but  the  loss  of 
bodily  heat  is  prevented. 

Having  called  attention  to  the  importance  of  the  employment 
of  heat  it  remains  for  us  to  utter  a  word  of  warning  against  the 
use  of  water  at  too  high  a  temperature.  This,  at  first  sight,  seems 
absurd,  as  the  merest  tyro  would  not  inject  very  hot  water  into  the 
rectum  or  use  it  over  the  surface  of  the  body,  yet  it  is  necessary  to 
have  a  moderate  degree  of  heat  and  no  more,  for  it  is  as  possible 
to  cause  heat  stroke  by  the  use  of  too  hot  water  as  it  is  to  chill  the 
patient  to  death  by  cold  injections.  The  following  experiment 
shows  this  very  clearly  : — 

Experiment. — Dog,  weight  50  pounds.     Full  grown. 

Temperature  of  water  injected  into  bowel  115°  F.  Pressure  of 
water  65  millimeters  of  mercury. 

12.27  Axillary  temperature  101.1°. 

12.35  Began  injection. 

12.40  Axillary  temperature  102°. 

12,55  Axillary  temperature  105°. 

1  Axillary  temperature  106°.  Marked  signs  of  heat  dyspnoea. 
Belly  walls  very  hot.  Vomited  water.  Time  of  passing 
water  through  from  anus  to  mouth  twenty-five  minutes 
at  a  pressure  of  65  millimeters. 

Having  found  that  water  at  the  temperature  of  115°  Fahr.  pro- 
duces symptoms  of  heat  stroke,  other  experiments  were  made  to 
determine  the  safest  temperature  in  every  case,  and  it  was  found 
that  the  water  should  be  at  about  105°  to  108°,  owing  to  the  fact 
that  so  much  of  the  heat  is  lost  by  the  slow  progress  of  the  water 
from  the  bag  to  the  anus,  through  the  connecting  rubber  tube.  If 
the  tube  be  very  short  the  temperature  need  not  be  above  103°. 


102  WOUNDS   AND   OBSTRUCTION   OF   THE   INTESTINES. 

The  following  experiment  shows  very  well  the  advantages  of  a 
moderate  temperature : — 

Dog,  weight  40  pounds.     Full  grown.     Axillary  temperature 

Injected  hot  water  at  110°  F.  from  anus  to  mouth. 

12.16  Began  injection;  pressure  15  to  20  mm.  Hg. 

12.20  Colon  full. 

12.24  Belly  very  distended.     Axillary  temperature  99 1°. 

12.30  Vomited  the  water.     Axillary  temperature  101'°. 

12.50  Seems  quite  well. 

It  will  be  seen  on  glancing  at  the  three  typical  experiments  which 
we  have  given,  in  which  cold,  hot,  and  warm  water  were  used,  that 
several  valuable  points  appear.  Where  cold  water  was  used  tlie 
animal  was  severely  chilled,  shocked,  and  in  collapse,  and  although 
he  was  only  27  pounds  in  weight  it  took  thirty  minutes  to  pass  the 
liquid  through  the  gut  from  end  to  end  at  a  pressure  of  35  milli- 
meters of  jnercury.  In  the  instance  where  the  heat  was  great  the 
dog  was  nearly  twice  as  large  (50  pounds),  and  it  required  only 
twenty-five  minutes  to  pass  the  water  through  the  gut  at  a  pressure 
of  65  mm.  of  mercury.  In  other  words,  the  increased  size  of  the 
dog  necessarily  called  for  nearly  double  the  pressure,  and  twice 
the  bulk  of  water,  but  the  heat  enabled  the  liquid  to  overcome  the 
muscular  resistance  which  was  met  with.  The  heat  was,  however, 
too  great,  and  heat  stroke  came  on. 

In  the  third  experiment,  the  temperature  of  the  water  in  the 
bag  was  at  110°  F.,  the  dog  weighed  forty  pounds,  and  only  had 
a  pressure  of  from  15  to  20  mm.  of  mercury  on  the  water.  Yet  in 
this  case  the  water  passed  through,  from  end  to  end,  in  fourteen 
minutes  without  any  untoward  effects,  and  the  animal  enjoyed  per- 
fect liealth  afterwards.  It  is  evident,  therefore,  that  four  things 
are  worthy  of  note  :  1st,  that  the  use  of  cold  injections  is  harmful ; 
2d,  that  they  cause  resistance  on  the  part  of  the  bowel;  3d,  that 
very  hot  water  goes  through  somewhat  faster,  but  causes  heat 
stroke ;  4th,  that  moderately  warm  water  passes  through  very 
rapidly  and  produces  no  ill  effects. 

From  the  results  of  our  studies  we  would  also  recommend  the 
addition  of  about  1  drachm  of  common  salt  to  each  8  ounces  of 
water  used,  for  it  was  found,  when  fresh  water  was  employed, 
and  a  post-mortem  examination   made,   tJiat   the   intestines  were 


SPECIAL   TREATMENT   OF   OBSTRUCTION.  103 

whitened  or  bleaclicd,  aud  often  spasmodieally  contracted  and  stif- 
fened. The  explanation  of  this  is  not  far  to  seek.  The  circulation 
of  a  salt  solution  containing  less  than  the  normal  quantity  of 
saline  (7  per  1000)  causes  an  absor[)tion  of  salts  from  the  sur- 
rounding tissues,  as  is  well  known  to  all  piiysiologists,  whereas  a 
solution  of  greater  strength  tlian  7  to  1000  causes  an  abstraction  of 
water. 

In  the  consideration  of  the  use  of  injections  in  intestinal  obstruc- 
tions, we  at  once  find  ourselves  face  to  face  with  the  question  as  to 
whether  the  pressure  exerted  upon  the  intestinal  contents  by  the 
distention  of  the  bowel  can  influence  the  heart  and  respiration  to 
any  appreciable  extent,  and  we  have  carried  out  a  series  of  studies 
to  cover  these  points,  with  the  result  of  finding  that  the  distention 
of  the  primae  vise  by  an  injection  as  it  passes  through  the  abdominal 
cavity,  has  no  more  effect  upon  the  system  in  general  than  the  pas- 
sage of  an  inflated  tube  through  the  centre  of  a  room  or  box.  This 
is  clearly  shown  by  the  following  tracing  obtained  by  attaching  the 
carotid  artery  of  a  dog  to  the  mercurial  manometer  and  taking  a 
tracing  as  the  injection  was  made.  The  slight  changes  occurring 
in  the  tracing  are  such  as  constantly  take  place  in  all  experiments, 
and  are  due  to  arhythmic  respiratory  movements. 

In  cases  of  obstruction,  therefore,  there  is  no  danger  in  using 
injections,  for  distention  of  the  intestinal  wall  of  brief  duration 
cannot  produce  ill  effects,  at  least  wdien  due  to  such  a  cause.  On 
the  other  hand  it  is  true  that  if  the  abdominal  contents  be  com- 
pressed by  liquids  outside  of  the  intestines,  that  is  free  in  the 
abdominal  cavity,  death  ^^-ill  take  place.  This  will  be  seen  in  the 
following  experiments  and  tracings,  the  lethal  result  being  due  to 
respiratory  failure,  produced  through  pressure  exerted  on  the  dia- 
phragm whereby  exhaustion  of  the  supplementary  respiratory 
muscles  ensued  as  a  result  of  diaphragmatic  paralysis.^ 

1  Since  making  these  studies  Heinricus  has  published  a  series  of  expei'iments 
made  by  him  of  identically  the  same  character  as  our  own,  which  reach  results 
of  a  similar  nature,  although  performed  in  the  pursuance  of  a  different  Hue  of 
study. 

See  Zeitschrift  fiir  Biologie,  1889. 

Delbert  (Annales  de  Gynecologie,  1889)  has  also  reached  the  same  results,  so 
that  it  may  be  said  that  three  different  researches,  performed  independently  of 
one  another,  are  in  accord. 


104  WOUNDS    AND   OBSTRUCTIOX   OF   THE   INTESTINES. 

Experiment. — Dog,  weight  70  pounds. 

Passed  into  tlic  belly,  through  a  small  trocar  pushed  through  the 
belly  wall,  a  sufficient  quantity  of  warm  water  to  produce  complete 
distention  and  finally  death.  The  abdominal  muscles  first  ceased 
to  act,  then  the  thoracic  muscles  failed,  and,  finally,  the  cervical 
muscles,  after  a  few  contractions,  gave  out. 

Post  morton. — The  liver  and  spleen  ^vere  dirty  brown  in  color 
and  contracted.  The  intestines  were  shrivelled,  contracted,  and 
empty,  except  the  duodenum  and  the  jejunum.  There  was  mode- 
rate venous  congestion  of  the  omentum  and  raesenteiy. 

Thinking  that  the  fatal  result  might  be  due  to  the  use  of  a  non- 
saline  fluid,  we  performed  the  following  test,  but  found  that  death 
was  still  the  result. 

Dog,  weight  70  pounds,     Newfoundland  pup. 

Passed  into  the  abdomen  warm  normal  saline  fluid  in  the  same 
manner  as  in  the  last  expei'iment,  but  death  occurred  in  the  same 
way.  On  section  the  liver  and  spleen  were  normal  in  color,  and 
there  w'as  no  shrinking  to  be  seen.  The  intestines  were  somew^hat 
rigid  from  contraction  of  their  muscular  walls.  The  trocar  had 
wounded  a  bloodvessel  in  the  mesentery  of  the  lower  part  of  the 
ileum,  and  an  extravasation  the  size  of  a  bean  was  found  at  this 
point  between  two  mesenteric  layers  (see  tracings). 

Abdominal  massage. — Hutchinson^  has  given  kneading  of  the 
abdomen  under  an  ansesthetic,  and  in  combination  with  injections, 
high  praise  as  a  treatment  for  intestinal  obstruction.  He  states  that 
the  only  cases  in  which  the  surgeon  is  the  least  likely  to  regret 
having  employed  it  are  those  in  which  peritonitis  simulates  ob- 
struction. 

It  must  not  be  forgotten  that  massage  is  a  treatment  which  is 
purely  empirical,  that  its  skilful  and  judicious  application  is  a 
matter  of  chance  in  the  obscurity  which  always  surrounds  these 
cases  of  obstruction,  and  that  not  only  may  it  be  absolutely  hurtful 
in  peritonitis,  but  may  immediately  determine  a  rupture  in  a  greatly 
distended  and  congested  loop  of  gut.  It  is  easy  to  see  how  it  vwy 
be  beneficial  in  every  form  of  acute  obstruction ;  but  to  so  apply  it 
that  it  necessarily  will  produce  the  result  desired  is  an  impossibility. 

1  Loc.  cit. 


Tracings  showing  the  primary  slight  effect  of  great  intra-abdominal  X-'i'^sure, 
with  ultimate  death  from  respiratory  failure.  Water  injected  into  abdom- 
inal cavity. 


1. 

[To  face  page  104. 

•iW 

WVVWiAA/lMA 

hi                ■A'f''':Tt'l 

III. 


IV. 


VI. 


^IWiffHW'i'M 


VII. 


Tracings  shovnng  effects  oj  passing  into  the  oMoniina.l  mvity  two  gallons 
.7  per  cent,  saline  solution  at  a  temperature  of  10^  F. 

I,  [To  face  pagf  104. 


MPMtH\J'H\MAN'^W^' 


3  ht^i^^^^fy^^- 


V. 


SPECIAL   TREATMENT   OF   OBSTRUCTION.  105 

The  use  of  metalHo  mercury. — The  use  of  nuitallic  rncr<Miry  in 
obstruction  is  certainly  rare  at  the  present  day.  Treves,  (jiiotinn- 
Matignon,  states  that  it  may  l)e  of  service  in  eases  of  ileus  following 
fecal  accumulation,  the  metal  becoming  finely  divided  and  so  coating 
aild  penetrating  the  obstructing  mass,  that  the  latter  is  loosened  and 
its  discharge  facilitated.  Matignon  states  that  in  no  instance  is 
mercurial  poisoning  produced,  that  pain  and  vomiting  are  quickly 
relieved,  and  that  frequently  there  is  a  prompt  evacuation  of  the 
bowel  contents  following  this  treatment,  and  this  after  all  other 
means  have  been  absolutely  fruitless.  Brown^  reports  a  case  of  ob- 
struction relieved  by  the  administration  of  seven  pounds  of  metallic 
mercury.  Plead^  injected  one  pound  into  the  rectum  of  an  infant 
aged  five  months  suifering  from  invagination,  and  by  inversion  of 
the  patient  attempted  to  effect  reduction.  The  child  recovered, 
but  this  was  not  attributed  to  the  mercury. 

In  spite  of  Matiguon's  assurance  as  to  the  innocuousness  of  this 
agent  there  is  reason  to  believe  that  its  result  may  be  disastrous. 
Crisp^  assigns  death  in  one  instance  to  the  administration  of  half 
an  ounce  of  mercury.  Oke^  reports  a  case  in  which  six  ounces 
caused  pouching  and  resultant  gangrene  on  the  proximal  side  of  a 
chronic  obstruction. 

The  special  application  of  metallic  mercury  would  seem  to  be  in 
cases  of  fecal  impaction  where  other  means  have  not  been  successful. 

Other  Means  of  Treatment. — The  rectal  tube  is  of  distinct 
value  in  the  beginning  of  paralytic  distention.  By  its  action  peris- 
talsis is  excited,  and  the  resistance  of  the  sphincter  is  overcome. 
Though  many  cases  are  reported  in  which  it  is  alleged  that  the 
point  of  the  tube  has  reached  the  csecum,  the  sharp  angularities  of 
the  sigmoid  and  its  free  mesenteric  attachment  are  probably  insuper- 
able obstacles  to  this.  The  attempt  to  reduce  an  invagination  or 
volvulus  by  means  of  a  stiff  tube  is  not  to  be  commended. 

Ice  to  the  abdomen. — The  arguments  against  cold  injections  also 
apply  to  external  application  of  ice.  In  the  obstruction  of  sup- 
purative peritonitis,  however,  when   the  temperature  is  high,  ice 

1  Soc.  Med.  Jonrn.,  London,  1853,  p.  117. 

2  St.  Barth.  Repts.,  1867,  III.  85. 

3  London  Lancet,  1847,  L.  557. 

*  Prov.  Med.  &  Surg.  Jouru.,  1852,  p.  293. 


106  WOUNDS    AND    OBSTRUCTION    OF    THE    INTESTINES. 

may  be  applied,  as  a  treatment  to  the  inflammation  ratlicr  than  the 
obstruction. 

Leaden  bullets, — These  have  been  swallowed,  literally  by  the 
hundred,- with  the  idea  of  sweeping  by  their  weight  impacted  feces 
from  the  bowel.     Such  treatment  is,  of  course,  to  be  condemned. 

Injections  of  ether. — This  agent  has  been  used  by  rectal  injection 
as  a  means  not  only  of  encouraging  peristalsis,  but  also  of  causing 
rapid  dilatation  by  vaporization.  Clause'  reports  two  successful 
cases  in  which  relief  was  immediate  on  the  injection  of  a  pint  of  a 
3  per  cent,  solution  of  ether. 

Position. — Cases  are  occasionally  reported  where  relief  followed 
upon  inversion  of  a  patient.  The  knee  elbow  position  is  said  to 
have  instantly  cured  a  case  of  marked  obstruction. 

1  II  Morgagni,  Sept.  1889. 


CHAPTER  XII. 

SURGICAL  TREATMENT  OF  INTESTINAL  OBSTRUCTION. 

Puncture  of  the  Abdomen. — This,  as  a  means  of  giving 
relief  in  excessive  tympany,  has  its  most  able  advocate  in  the 
person  of  Ogle,'  who  has  gleaned  from  medical  literature  positive 
proofs  of  its  extensive  employment  and  the  great  improvements,  at 
times  positive  cures,  attributable  to  it.  In  cases  of  metcorism  suffi- 
ciently developed  to  seriously  embarrass  the  respiratory  functions, 
he  advocates  one  or  more  punctures  into  the  distended  gut  by  means 
of  an  aspirator  or  hypodermic  needle,  and  the  withdrawal  of  as 
much  gas  as  possible.  This  is  followed  by  immediate  relief. 
Rosenbach,^  on  a  basis  of  four  cases,  two  of  which  were  cured, 
the  remainder  greatly  benefited  by  this  procedure,  directs  that  the 
punctures  should  be  made  in  the  most  distended  part  of  the  abdo- 
men, that  the  needle  should  be  entered  gently,  and  that  after  the 
evacuation  a  few  drops  of  carbolic  solution  or  iodoform  oil  should 
be  injected  to  disinfect  the  puncture  track.  He  states  that  this 
procedure  has  never  been  followed  by  an  infectious  peritonitis. 
Stuckey,^  in  a  case  of  laparotomy  and  enterorraphy  for  gunshot 
wound,  reduced  tympany  by  a  number  of  minute  punctures  made 
with  the  point  of  a  lancet;  the  patient  recovered. 

Demons  reported  six  cases  of  puncture  with  successful  results  in 
each  instance.  Unfavorable  comments  upon  this  method  are,  how- 
ever, not  far  to  seek.  Morris,  Bryant,  Bristowe,  and  Curtis  all 
point  out  the  great  danger  of  fecal  extravasation  following  even  a 
minute  puncture  in  a  dilated  bowel,  and  cite  cases  in  support  of 
their  objection.  Curschmann,  while  warmly  advocating  punctures, 
advises  against  them  in  peritonitis. 

We  believe  that  punctures  are  of  distinct  service  in  excessive  and 
dangerous  tympany.  They  should  be  made  by  means  of  the  h}"po- 
dermic  or  fine  aspirating  needle,  and  under  rigid  antiseptic  precau- 

1  On  the  Relief  of  Tympanites  by  Puncture  of  the  Abdomen,  London,  1SS8. 

2  Berlin.  Klin.  Woch.,  1889,  No.  21.  s  Med.  Record,  Nov.  21,  1S85. 


108  WOUNDS   AND   OBSTRUCTION   OF   THE   INTESTINES. 

tions.  The  needle  should  be  driven  in  with  a  sudden  violent  thrust, 
the  thumb  guarding  against  too  deep  penetration ;  by  this  means 
there  is  less  danger  of  tiie  bowel  being  ])ushcd  before  the  point  of 
the  instrument  rather  than  being  penetrated  by  it.  A  fine  rod  or 
wire  should  be  provided  for  clearing  the  canal  of  the  needle  in  ease 
it  becomes  blocked.  As  many  punctures  should  be  made  as  are 
necessary  for  the  entire  relief  of  pressure  symptoms.  There  can 
be  no  objection  to  causiug  collapse  of  all  the  visible  bowel  coils. 
The  lumen  of  the  needle  should  be  flushed  out  with  an  antiseptic 
solution  before  withdrawal.  If  the  muscular  coat  of  the  bowel 
retains  the  slightest  amount  of  tonicity  the  puncture  will  be  imme- 
diately closed,  since,  as  the  gut  contracts,  the  relative  change  in 
the  opening  through  the  various  coats  at  once  occludes  the  minute 
canal. 

If  the  gut  is  in  a  condition  of  absolute  and  hopeless  paralysis, 
then  feces  may  leak  through  even  the  minute  opening  made  by  an 
aspirator  needle.  The  condition  of  these  cases  is,  however,  usually 
so  desperate  that  it  is  a  question  as  to  whether  any  means  offers  the 
slightest  prospect  of  hope.  As  to  the  penetration  of  the  gut  with  a 
large  sized  trocar  and  canula,  the  latter  being  allowed  to  remain  in 
place  for  the  evacuation  of  the  intestinal  contents,  such  a  procedure 
is  to  be  absolutely  condemned. 

Enterostomy. — This  name  has  been  proposed  by  Curtis  for  the 
operation  of  securing  any  portion  of  the  small  or  large  intestines  to 
the  abdominal  parietes  and  making  an  artificial  anus.  By  Nelaton, 
who  particularly  favored  it,  this  procedure  when  the  small  intestine 
was  involved  was  termed  enterotomy,  the  term  colotomy  being 
applied  to  the  formation  of  a  more  or  less  permanent  opening  in 
the  colon. 

The  operation,  when  it  concerns  the  small  intestine,  consists, 
briefly,  in  an  incision  commonly  placed  in  the  right  iliac  region, 
into  which  is  secured  the  first  distended  intestinal  coil  which  pre- 
sents by  a  line  of  sutures  apposing  its  surface  to  the  entire  circum- 
ference of  the  peritoneum  about  the  parietal  wound,  the  skin  and 
peritoneum  lining  the  two  surfaces  of  which  have  been  previously 
united  by  a  continuous  suture. 

The  gut  is  then  incised  and  its  contents  evacuated,  thus  establish- 
ing an  artificial  anus. 


SURGICAL    TREATMENT    OF    INTESTINAL    OHSTRUCTION.       109 

The  mortality  of  non-malignant  eases  is,  according  to  l*eyrot  and 
Treves's  tables,  67  per  cent. 

Curtis^  statistics  are  far  more  favorable,  indeed  he  is  tlie  most 
able  advocate  of  this  proccdnre  in  recent  years,  and  his  results  go 
far  to  confirm  Banks's  prophecy  that  this  is  the  operation  of  the 
future.  In  a  total  of  62  cases,  relief  to  the  obstruction  was  obtained 
in  42  (76  per  cent.).  The  moi^tality  was  48.3  per  cent.,  32  cases 
recovering.  In  19  of  these  recovered  cases  normal  passages  were 
resumed,  the  recovery  thus  being  complete  and  definite.  This  gives 
us  then  complete  recovery,  i.  e.,  with  closure  of  the  artificial  anus, 
in  30|-  per  cent.,  of  all  cases,  and  partial  recovery,  the  bowel  opening 
remaining  patulous  in  a  further  21  per  cent.  Comparing  these  re- 
sults with  abdominal  section  we  find  that  the  latter  operation  gives  a 
mortality,  fj-om  Ashhurst's  346  cases,  of  69  per  cent.  Enterostomy 
gives  then  a  recovery  as  complete  as  the  best  that  can  be  afforded 
by  laparotomy  in  practically  the  same  percentage  of  cases  (31  per 
cent,  in  laparotomy,  30|-  per  cent,  in  enterostomy).  Moreover,  it 
gives  a  further  percentage  of  21  per  cent,  of  partial  cures,  the 
artificial  anus  persisting.  Of  course  if  the  surgeon  takes  the  view 
that  death  is  not  more  to  be  dreaded  than  an  artificial  anus,  so  far 
as  the  statistical  study  goes,  he  will  find  little  choice  between  the 
operations.  If,  however,  the  life  of  his  patient  is  the  prime  object, 
enterostomy  will  be  an  operation  to  which  he  will  at  times  resort. 
It  has  been  clearly  shown  that  by  relief  of  pressure  obtained  by 
enterostomy,  intussusception,  volvulus,  and  even  internal  strangu- 
lation may  undergo  spontaneous  cure.  It  is  not  from  the  study  of 
individual  and  peculiar  cases  that  the  general  rules  of  surgical 
procedures  are  drawn,  but  rather  from  conditions  and  results 
observed  in  the  majority  of  such  cases.  Hence  because  exception- 
ally a  patient  perishes  after  enterostomy  from  gangrene  dependent 
upon  the  constriction  of  a  band  which  laparotomy  might  have 
exposed  and  enabled  the  surgeon  to  divide  it  must  not  be  con- 
cluded that  the  simpler  operation  is  so  imperfect  that  it  should  be 
utterly  rejected.  On  the  contrary,  we  must  recollect  that  abdominal 
section  is,  in  the  majority  of  cases,  followed  by  death ;  that  ente- 
rostomy relieves  many  cases,  which  if  subjected  to  section  would 

1  Med.  Record,  Sept.  1,  18S8. 


110  WOUNDS   AND   OBSTRrCTION   OF   THE   INTESTINES. 

surely  die,  and  that  exceptional  instances  are  valuable  in  drawing 
conclusions  in  proportion  to  their  frequency. 

We  believe  that  in  all  cases  where  the  probable  cause  and  seat 
of  intestijial  obstruction  cannot  be  diagnosed,  and  where  meteorism 
is  well  marked,  the  surgeon  having  decided  to  operate  should  per- 
form enterostomy  ;  and  this  is  indicated  as  the  preferable  operation 
still  more  decidedly  if  the  patient's  circulation  has  begun  to  show 
the  effect  of  his  malady. 

CoLOTOMY,  which  we  consider  under  the  heading  Enterostomy, 
is,  of  course,  an  operation  applicable  only  when  either  the  colon, 
sigmoid  flexure,  or  rectum  is  subject  to  obstruction.  It  is  a  proce- 
dure rarely  resorted  to  except  for  chronic  obstruction  or  for  an 
acute  attack  occurring  in  the  course  of  the  chronic  disorder.  Yet 
both  volvulus  and  invagination  may  produce  sudden  obstruction 
at  the  termination  of  the  large  intestine,  and  may  demand  for 
immediate  relief  an  incision  into  the  gut.  In  this  case  the  indica- 
tions for  enterostomy  being  plain,  the  right  inguinal  incision  may 
be  made  with  the  idea  of  opening  the  first  prominent  loop  of  small 
intestine.  If  the  caecum  is  dilated,  however,  the  incision  should  be 
made  here,  as  it  is  found  that  there  is  not,  as  has  been  claimed,  a 
reguj'gitation  of  feces  through  the  ileo-csecal  valve. 

Of  colotomy,  when  the  obstruction  is  in  or  about  the  rectum, 
both  the  iliac  and  lumbar  operation  have  their  enthusiastic  advo- 
cates. 

Bryant  still  warmly  recommends  the  lumbar  operation  in  all 
cases  complicated  by  distention,  and  acute  in  nature,  claiming  that 
in  this  condition  the  procedure  he  commends  is  both  easier  and 
safer,  and  gives,  from  a  statistical  study,,  a  greater  percentage  of 
successes.  Batts's  244  cases  of  lumbar  colotomy  give  a  mortality  of 
32  per  cent.  The  inguinal  operation,  however,  gives  a  mortality 
of  over  50  per  cent.  Cripps  still  urges  the  latter  operation,  claim- 
ing that  it  is  more  easily  performed,  is  more  likely  to  successfully 
open  the  colon,  and  makes  a  more  convenient  opening.  The  in- 
guinal operation  in  addition  to  its  other  advantages  enables  the 
surgeon  to  explore  the  peritoneal  cavity. 

The  bowel  should  be  drawn  down  to  its  full  extent  to  prevent 
prolapse,  should  be  sutured  to  the  united  skin  and  peritoneum,  and 
subsequently  should  be  opened.      Or  Madyl's  operation  may  be 


SURGICAL   TREATMENT   OF   INTESTINAL   OBSTRUCTION.       Ill 

performed,  the  giit  being  held  in  the  wound  by  metms  of  a  hard 
rubber  tube  passed  transversely  across  it  and  through  its  mesentery ; 
the  periphery  of  the  gut  is  then  sutured  to  the  parietal  peritoneum, 
which  has  j)reviously  been  sutured  to  the  skin. 

If  there  is  an  idea  of  subsequently  closiug  this  opening  a  longi- 
tudinal incision  is  made  in  the  gut.  Then  when  the  permeability 
of  the  rectum  is  re-established  the  supporting  tube  is  withdrawn 
and  the  bowel  spontaneously  retracts  and  closes.  If  a  permanent 
artificial  anus  is  necessary  the  bowel  is  cut  transversely  across,  and 
sutured  in  place. 

Abdominal  Section. — By  abdominal  section,  as  applied  in  intes- 
tinal obstruction,  is  meant  the  fornaal  opening  of  the  abdominal 
cavity  with  the  idea  of  searching  for  the  seat  of  obstruction  and 
removing  the  exciting  cause.  It  is  the  ideal  operation,  since,  if 
successful,  the  parts  are  immediately  restored  to  their  normal  con- 
dition. From  a  statistical  standpoint,  though  the  proof  thus 
offered  is  of  little  value,  section  offers  practically  as  favorable 
results  as  expectant  treatment.  In  one  table  we  have  the  records 
of  197  cases  of  obstruction  not  operated  upon,  and  of  which  148 
died,  giving  a  mortality  of  73.2  per  cent.,  while  of  the  38  operative 
cases  27  died,  giving  a  mortality  of  71  per  cent.  This  death  rate 
corresponds  closely  with  that  given  by  Ashhurst  in  his  elaborate 
tables. 

Even  though  the  statistical  study  of  this  subject  is  of  no  value 
in  making  a  comparison  between  the  results  of  the  operative  and 
non-operative  treatment,  the  fact  remains  that  many  cases  have 
recovered  from  operation  who  inevitably  would  have  perished  had 
expectant  treatment  been  continued.  Is  there  to  be  contrasted 
with  this  a  series  of  cases  which  might  have  undergone  spontaneous 
resolution,  but  for  the  operative  interference  ?  We  think  the  answer 
to  this  must  be,  with  some  reservation,  in  the  negative.  With 
reservation  because  undoubtedly  cases  have  been  lost  because  of  the 
surgeon's  desire  to  do  too  much,  to  find  and  remedy  the  obstruction 
regardless  of  the  patient's  condition.  Such  patients  might  have 
survived,  not  by  being  treated  medically,  but  by  being  subjected 
to  a  more  conservative  surgical  operation.  We  think,  in  acute 
cases,  the  indications  for  abdominal  section  are  as  yet  limited. 


112  WOUNDS   AND   OBSTRUCTION   OF   THE   INTESTINES. 

They  may  be  formulated  by  stating  that  this  operation  should  be 
performed — 

In  unreduced  invagination  in  impacted  foreign  body,  in  internal 
strangulation  and  in  volvulus,  if  the  seat  of  trouble  can  be  diag- 
nosed before  operation. 

In  cases  of  intestinal  obstruction  the  nature  and  seat  of  Mliicli 
are  unknown,  if  seen  early,  when  the  meteorism  is  not  yet  devel- 
oped and  when  strength  is  well  preserved. 

In  peritonitis  of  all  varieties,  where  there  is  pus  or  septic  effusion 
in  the  abdominal  cavity. 

Paralytic  distention  is,  we  think,  better  relieved  by  multiple  punc- 
tures, since  the  shock  of  a  formal  section  is  liable  to  increase  the 
intestinal  paralysis  even  though  the  distention  is  relieved  by  inci- 
sion. To  be  sure  punctures,  exceptionally,  result  disastrously,  but 
as  death  is  the  rule  after  section  for  this  condition,  we  think  the 
surgeon  is  justified  in  first  resorting  to  the  least  dangerous  expedient. 

Where  in  spite  of  puncture  death  is  steadily  approaching  with 
the  symptoms  of  intestino-peritoneal-septicfemia  there  should  be 
no  hesitation  in  opening  the  abdomen,  irrigating  its  cavity  and 
evacuating  the  intestinal  contents  by  small  transverse  incisions, 
these  latter  to  be  immediately  closed  by  Lembert  sutures. 

Where  the  seat  and  nature  of  the  obstruction  are  unknown,  a 
free  median  sub-umbilical  incision  should  be  made,  and  the  hand 
should  at  once  be  carried  to  the  cfecum.  If  this  part  of  the  bo'\\'el 
is  inflated  the  obstruction  will  necessarily  be  in  the  large  intestine ; 
if  flaccid  and  empty,  or  containing  only  feces,  the  small  intestine 
will  have  to  be  searched  for  the  seat  of  blocking.  It  is  a  good 
general  rule  to  search  for  the  empty  intestinal  loops,  and  trace  them 
along  till  the  distended  part  is  reached,  not  only  because  there  is 
a  probability  of  thus  reaching  the  seat  of  obstruction  much  more 
quickly,  but  because  handling  of  the  inflated  gut  is  thus  avoided. 

We  think  it  is  important,  in  all  these  manipulations,  to  keep  the 
gut  constantly  covered  with  sheets  of  rubber  dam,  and  to  avoid, 
except  in  case  of  absolute  necessity,  withdrawing  any  large  part  of 
the  intestines  from  the  abdominal  cavity.  Where  this  is  required 
hot  sponge  cloths  and  rubber  sheeting  should  protect  and  keep 
warm  the  exposed  intestine.  If  the  seat  of  obstruction  cannot  be 
readily  found,  and  the  operator  is  hampered  for  want  of  room, 
there  should  be  no  hesitation  in  enlarging  the  incision,  even  carry- 


SURGICAL   TREATMENT    OP    INTEBTINATv    OBSTRUCTION.       113 

ing  it  to  the  entiform  proeoHS  if  necessity  requires,  or  making  a 
transverse  cut  toward  one  or  tlie  otJier  lumbar  region.  Wc  think 
that  thirty  minutes  is  the  extreme  limit  of  time  allowable  for  search 
if  the  seat  of  trouble  is  difficult  to  find.  Failing  in  that  time  the 
loop  of  intestine  nearest  the  occlusion  should  be  secured  in  the 
external  wound,  and  an  artificial  anus  should  be  formed. 

Even  though  the  obstruction  is  found,  it  may  be  discovered  that 
it  cannot  be  relieved  without  prolonged  and  extensive  operative 
procedure. 

The  difficulty  may  depend  upon  a  great  mass  of  small  intestines 
bound  together  by  tight  adhesions.  It  may  be  due  to  an  invagina- 
tion so  tightly  adherent  that  disinvagination  is  impossible,  or  a 
volvulus  which  in  spite  of  puncture  and  reduction  immediately 
springs  back  to  its  twisted  condition,  or  extensive  adhesions  of  an 
old  or  recent  peritonitis — or  even  if  the  obstruction  is  of  such  a 
nature  as  to  be  readily  overcome,  the  bowel  may  be  already 
gangrenous. 

Under  these  circumstances  an  artificial  anus  should  be  formed. 
It  may  happen,  however,  that  a  mass  of  adherent  intestinal  coils,  say 
in  the  upper  part  of  the  ileum,  are  causing  obstruction.  Adhesions 
are  so  tight  and  extensive  that  freeing  them  is  obviously  hopeless. 
An  artificial  anus  formed  on  the  proximal  side  of  this  obstruction 
will  certainly  result  fatally  from  inanition.  Here,  we  think,  a 
lateral  anastomosis  by  bone  plates,  catgut  rings,  or  by  ordinary 
rubber  drainage  tube  rings  is  indicated. 

Where  the  bowel  is  gangrenous  and  requires  resection,  the  con- 
tinuity of  the  canal  may  be  restored  by  invaginating  each  end  and 
closing  it  by  Lembert  sutures,  then  performing  a  lateral  anastomo- 
sis, or  end  to  end  approximation,  either  by  Senn's  method  or  by 
making  use  of  the  rubber  drainage  tube  where  the  catgut  or  rubber 
band  is  not  to  be  obtained. 

It  may  not  be  amiss  to  mention  here  the  method  of  apposition 
by  rubber  drainage  tube  rings.  It  is  practically  identical  with  that 
described  by  Senn,  except  that  in  place  of  bone  plates  we  use  an 
ordinary  small  drainage  tube. 

As  a  result  of  numerous  experiments  we  are  convinced  that  it 
has  nearly  all  the  advantages  of  the  decalcified  bone,  and  moreover 
it  is  always  at  hand  when  the  surgeon  needs  it  and  can  be  imme- 
diately adjusted  to  any  required  size.     One  year  ago  we  began  our 


114  WOUNDS    AND    OBSTRUCTION    OF   THE    INTESTINES. 

experiments  ^\  ith  these  rings,  since  on  account  of  tlie  time  required 
in  the  i)repai'ation  of  both  Scnn's  and  Abbe's  plates  we  believed 
they  ^vould  not  be  widely  used  by  surgeons.  As  far  as  experimen- 
tal work-  goes,  we  have  demonstrated^ — 

1.  That  approximation  rings  each  made  of  a  single  rubber  drain- 
age tube  produce  tight  apposition  of  two  apposed  bowel  loops. 

2.  That  the  rings  are  subsequently  discharged  per  anum  without 
difficulty. 

3.  That  they  can  be  made  and  applied  in  a  very  few  minutes. 

4.  That  the  elastic  pressure  they  afford  is  of  distinct  advantage. 

5.  That  for  end  to  end  invagination  by  Senn's  modification  of 
Jobert's  method  these  rings  are  satisfactory,  but  are  not  so  desirable 
as  Senn's  flat  rubber  ring. 

6.  That  for  end  to  end  approximation  these  rings  are  well 
adapted. 

In  the  construction  of  the  riugs  a  piece  of  drainage  tube  of 
appropriate  length  is  cut  obliquely  across  the  two  ends ;  these  ends 
are  then  approximated,  thus  making  an  oval,  and  held  in  place  by 
catgut  suture.  If  a  circular  ring  is  desired  the  ends  are  cut  off" 
square. 

Finally  six  sutures  armed  with  needles  are  secured  to  the  ring, 
and  it  is  ready  to  be  placed.^ 

AVe  have  confirmed  Senn's  experiments  m  regard  to  quicker  and 
firmer  union  following  scarification  of  the  apposed  peritoneal  sur- 
faces, and  we  believe  that  this  procedure  should  always  precede 
approximation.  The  suture  material  we  have  always  used  in  our 
intestinal  researches  is  catgut ;  we  think  this  is  least  likely  to  be 
followed  by  perforation,  since  by  its  swelling,  it  entirely  fills  the 
aj)erture  made  by  the  needle,  and  by  its  rapid  absorption  the 
seton-like  action  of  the  silk  thread  is  avoided.  Although  perito- 
nitis from  giving  way  of  catgut  suture  has  occurred,  we  do  not 
recall  any  instance  where,  experimentally  or  in  actual  practice, 
this  result  has  followed  from  ulceration  along  the  tj'ack  of  the 
suture. 

1  As  one  typical  of  a  series  of  experiments  we  give  the  following  : — 

June  14,  '89.     Pup.  aet.  7  rao.,  wt.  20  pounds. 

Etlierized,  belly  opened,  gut  cut,  lateral  anastomosis  by  means  of  two  rings 
made  of  ordinary  drainage  tube.  Two  rings  passed,  one  on  third  and  one  on 
fifth  day.  Remained  in  perfect  health  for  several  months.  Was  then  lost 
sight  of. 


SURGICAL   TREATMENT    OF    INTESTINAL    OBSTRUCTION.       115 

If  catgut  is  used  it  must  be  strong  and  aseptic.  The  surgeon 
should  personally  prepare  his  sutiu'e  material  in  these  cases — first, 
testing  its  strength,  tlien  subjecting  it  to  the  ordinary  processes, 
with  every  attention  to  cleanliness  and  thoroughness.  Corrosive 
sublimate  or  carbolic  acid  may  be  added  to  the  absolute  alcohol  in 
which  it  is  finally  stored.  Firm  adhesion  can  be  expected  in  eigh- 
teen to  thirty-six  hours,  and  the  catgut  never  yields  before  that 
time.  It  is  true  that  silk  knots  are  less  likely  to  slip  than  those 
of  catgut,  still,  as  this  is  a  matter  of  nicety  of  manipulation  on 
the  part  of  the  surgeon,  it  does  not  constitute  an  insuperable  objec- 
tion to  the  use  of  catgut. 

Since  the  original  unpublished  experiments  performed  by  us 
with  the  rubber  ring  as  a  means  of  producing  implantation  and 
anastomosis,  Brokaw^  has  described  practically  the  same  means  of 
accomplishing  this  object.  He  directs  that  the  ring  shall  be  made 
by  passing  a  catgut  strand  through  the  In  mi  n  a  of  several  small  sec- 
tions of  drainage  tube.  As  the  catgut  is  softened  the  ring  breaks 
into  its  several  small  portions,  and  is  discharged.  He  describes 
by  this  method,  impkntation  and  approximation,  with  successful 
experimental  result.  In  place  of  six  ligatures  he  uses  but  four. 
Senn  and  other  experimenters  state  that  this  is  a  sufficient  number. 
We  have,  however,  so  frequently  been  compelled  to  place  reinforcing 
sutures  to  prevent  eversion  of  a  portion  of  the  wound  edge  when 
four  sutures  were  used  that,  as  a  routine,  we  have  been  in  the  habit 
of  employing  the  two  extra  ones  as  described. 

The  technique  of  approximation  and  implantation  methods  has 
been  so  recently  and  fully  described  in  current  medical  literature, 
that  a  minute  detailed  description  seems  superfluous. 

Senn's  modifications  of  much  older  methods  are  practically  the 
operations  of  the  day.  The  intestinal  anastomosis  of  Maisonneuve, 
the  end  to  end  suture  of  Gely,  Jobert,  Lembert,  Czerny,  all  bril- 
liant operations  and  crowned  with  many  successes,  must  yield  to  the 
quicker,  safer,  and  equally  efficient  procedures  of  a  later  date. 

The  importance  of  the  element  of  time  has  long  been  recognized 
in  these  abdominal  operations.  It  was  partly  this  which  led  Denans 
to  propose  his  three  suture  rings,  two  j^laced  each  some  little  distance 
within  an  end  of  the  divided  bowel,  the  third  arranged  so  that  these 

1  Med.  News,  Nov.  30,  1889. 


116  AVOUNDS    AND    OBSTRUCTION   OF    THE    INTESTINES. 

two  Avere  clamped  togetlicr,  approximating  the  serous  coats.  This 
method  eh)sely  resembles  the  modern  end  to  end  ajiproxiination. 
Bandens,  somewhat  later  (1840),  devised  a  still  more  ingenious 
method."  Into  the  lower  extremity"  of  the  cut  bowel,  two  lines 
deep,  he  placed  a  metal  ring,  coi:cave  and  furrowed  upon  its  outer 
surface,  to  receive  and  hold  an  elastic  ring.  This  elastic  ring  was 
placed  in  the  upper  bowel  segment,  three  lines  deep,  the  edges  of  the 
bowel  being  folded  in  over  it.  The  upper  ring  was  then  stretched 
over  the  lower,  thus  producing  and  holding  in  place  a  local  invagi- 
nation. He  operated  upon  animals,  nsing  this  method  with  suc- 
cessful results. 

Whether  the  rubber  rings  and  decalcified  bone  plates  prepared 
by  Senn,  the  segmented  rubber  tubes  of  Brokaw,  the  catgut  rings 
of  Abbe,  the  catgut  plates  and  mats  of  Davis,  or  the  rubber  tube 
prepared  by  ourselves  be  used,  the  operative  procedures  are  practi- 
cally the  same. 

Lateral  apposition. — In  these  operations  two  portions  of  the  gut, 
or  the  gut  and  a  hollow  viscus,  having  been  arranged  side  by  side, 
so  that  they  both  pass  in  the  same  general  direction,  are  opened, 
each  upon  its  convex  apposed  surface.  An  approximating  ring, 
with  sutures  attached,  is  passed  into  the  bowel,  and  arranged  so  that 
it  surrounds  the  opening  ;  the  sutures  are  then  passed  through  the 
gut  wall  from  within  outward.  When  both  plates  are  in  position 
by  tying  the  corresponding  sutures  of  the  two  plates  together,  the 
openings  are  fixed  to  each  other,  and  a  false  passage  is  established. 

This  apprcximatioii  may  be  strengthened  by  a  few  Lembert 
sutures  placed  peripherally. 

End  to  end  approximation. — This  is  performed  by  passing  two 
rubber  rings,  each  respectively  within  the  lumen  of  the  upper  and 
lower  bowel  segment.  The  rings  are  placed  a  fourth  of  an  inch 
from  the  cut  extremities,  then  alloAving  the  latter  to  be  somewhat 
invaginated.  The  sutures  are  passed  through  the  bowel  walls  and 
tied  each  with  its  fellow  of  the  opposite  ring.  Around  the  whole 
is  placed  the  continuous  Lembert  suture  of  fine  catgut. 

Semi's  modification  of  Joberfs  invo.gination. — In  performiug  this 
operation  it  is  necessary  to  know  which  is  the  upper  and  which  the 
lower  bowel  segment  since  invagination  made  in  the  wrong  direc- 
tion might  result  disastrously.  With  the  idea  of  determining  this 
we  made  many  experiments  with  Nothnagel'  test,  but  in  every  case 


SURGICAL   TREATMENT   OF    INTESTINAL    OBSTRUCTION.       117 

were  disappointed,  the  peristalsis  prodiujcd  by  the  saline  either 
remaining  loeal,  or  becoming  diffused  so  slowly  that  it  was  impos- 
sible to  distinguish  it  from  the  vermicular  motion  taking  place  in 
other  parts  of  the  bowel.  As  Nothnagel  himself  now  denies  the 
existence  of  reversed  peristalsis,  we  are  at  a  loss  to  account  for 
the  abundant  corroborative  testimony  his  first  observations  have 
received.  Even  by  means  of  electric  currents  we  were  unable  to 
inaugurate  peristaltic  waves  so  distinct  by  their  direction  as  to  be 
of  practical  service.  The  oblique  attachment  of  the  mesentery 
from  above  downward  and  from  left  to  right  will  act  as  a  guide 
if  the  bowels  are  normally  placed,  but  this  is  so  frequently  not  the 
case  that  a  careful  tracing  of  the  intestine  to  seek  the  duodenum  or 
the  ileo-csecal  valve  may  be  necessary. 

If  this  is  necessary  we  would  recommend  a  procedure  suggested 
by  Bulteau,^  namely,  passing  through  the  mesentery,  first,  a  white 
suture,  then  an  inch  removed  in  the  direction  of  the  search,  one 
of  different  color.  We  have  seen  much  time  lost  from  the  operator 
being  required,  after  having  found  the  ileocsecal  valve,  to  labor- 
iously retrace  his  steps  to  discover  in  which  direction  he  had  been 
travelling. 

The  direction  of  the  intestinal  canal  having  been  decided  upon, 
the  upper  bowel  or  intussusceptum  receives  into  its  lumen  a  rubber 
band  one-third  inch  wide,  turned  in  the  form  of  a  ring,  and  secured 
with  catgut  sutures.  To  this  band  the  cut  border  of  the  gut  is 
secured  by  a  continued  suture,  thus  preventing  eversion  of  mucous 
membrane.  Two  catgut  sutures  each  threaded  with  two  needles 
are  then  passed  from  within  outward  through  the  upper  portion  of 
the  rubber  ring  and  the  gut  wall,  the  one  not  far  from  the  mesen- 
teric attachment,  the  other  on  the  opposite  convex  side  of  the  bowel. 
These  needles  are  then  passed,  at  corresponding  points  of  the  lower 
gut  end  and  about  a  third  of  an  inch  from  the  margin,  through  all 
the  coats  but  the  mucous  ;  by  gently  drawing  on  these  sutures,  and 
turning  in  the  edges  of  the  lower  segment  invagination  is  accom- 
plished so  completely,  that  Senn  states  no  reinforcing  sutures  are 
necessary. 

In  circular  enterorraphy  or  end  to  end  approximation  or  invagi- 
nation, great  attention  must  be  paid  to  the  mesenteric  attachment 

1  Be  rOcclus.  Iiitest.,  Par.  1878. 


118  "WOUNDS    AND    OBSTRUCTION    OF    THE    INTESTINES. 

of  the  gut,  Dot  only  becanse  tliis  is  the  only  part  of  the  bowel 
eirc'innference  uncovered  by  peritoneum,  but  because  the  constant 
traction  by  the  mesentery  is  exceedingly  likely  to  destroy  the  close 
approximation  at  this  point ;  therefore  most  operators  are  careful 
to  place  sutures  in  this  region  with  great  accuracy.  Tlie  ])erito- 
neum  should  be  neatly  brought  together  by  additional  stitches  in 
cases  of  enterorraphy,  or  strengthened  by  the  placing  of  one  or  two 
extra  threads  where  the  other  operations  are  performed. 

Implantation. — Ileo-colostomy  for  obstructions  about  the  ileo- 
cecal valve  is  best  performed  by  this  method.  The  bowel  having 
been  divided,  and  the  distal  end  washed  out,  invaginated  and 
sutured  so  that  it  is  tightly  and  permanently  closed,  the  proximal 
end  is  lined  with  a  rubber  ring  and  transfixed  with  sutures,  as  in 
case  of  invagination.  An  incision  of  size  appropriate  to  receive 
the  ileum  is  then  made  in  the  colon.  The  sutures  are  passed 
through  all  but  the  mucous  coat  of  the  latter,  and  by  traction  upon 
them  the  ileum  is  invaginated  into  the  large  intestine.  Brokaw 
has  proposed  to  modify  this  operation  by  placing  one  ring  in  the 
colon,  the  other  in  the  ileum,  and  bringing  the  bowel  together  by 
tying  the  corresponding  sutures  of  the  two  rings  together.  We 
have  not  yet  had  an  opportunity  of  trying  this  modification,  but 
theoretically  cannot  see  its  value,  the  ordinary  procedure  being 
rapidly  executed  and  giving  perfect  results.  In  case  section  of  the 
bowel  is  not  indicated,  ileo-colostomy  by  lateral  apposition  by  means 
of  rubber  rings  or  plates  can,  of  course,  be  performed. 

It  must  be  borne  in  mind  that  all  traumatism  of  the  bowel 
operative  or  otherwise  is  followed  by  local  paralysis,  and  that  this 
is  liable  to  occasion  temporary  obstruction.  The  paralysis  is  purely 
conservative  in  its  action  and  allows  of  fixation  of  the  bowel  till 
exudation  and  plastic  adhesion  has  to  an  extent  guarded  against 
the  danger  of  extravasation.  The  practical  deduction  from  this  is 
that  absolutely  nothing  should  be  given  by  the  mouth  till  this 
paralysis  and  obstruction  has  yielded.  Thirst  can  be  relieved  by 
the  rectum,  (see  Treatment  of  Obstruction)  and  medication  can  be 
administered  subcutaneously. 

Senn's  suggestions  in  regard  to  strengthening  the  line  of  suture 
by  omental  grafts  were  so  striking  that  we  at  once  proceeded  to 
experiment  upon  the  subject.  There  is  certainly  no  doubt  of  the 
quick  union  which  forms  between  transplanted  flaps  and  the  imnie- 


SURGICAL    TREATMENT    OF    INTESTINAL    OBSTRUCTION.       119 

diate  environment  of  a  line  of  snturo,  especially  after  searifieation 
of  the  latter.  We  have  seen  flaps  so  closely  adh(T(;nt  in  four  days 
that  their  removal  was  difficult  and  was  attended  with  bleeding. 
Our  experiments  show,  however,  that  these  flaps  arc  more  com- 
monly followed  by  extensive  adhesions  than  where  no  such  rein- 
forcement is  employed.  This  seemed  so  constant  in  our  ordinary 
suture  experiments  that  we  made  one  observation  with  the  sole 
purpose  of  determining  the  point. 

Experiment. — Dog,  weight  27  lbs.  Etherized;  convexity  of 
small  intestine  seared  with  red  hot  iron  in  three  spots,  each  two 
inches  apart.  Each  burn  was  half  an  inch  long  and  one-sixth 
inch  wide.  Middle  burn  covered  with  omental  flap  overlapping  it 
one-fourth  inch,  secured  by  four  fine  catgut  sutures.  Killed  in  one 
week.  Omentum  adherent  to  all  points  of  burning.  Eeadily 
stripped  from  areas  not  grafted.  Impossible  to  strip  omentum 
from  graft  area  without  injuring  gut.  This  part  of  gut  together 
with  its  adherent  omentum  glued  tightly  to  parietal  incision. 

It  would  thus  seem  that  omental  grafts  are  of  distinct  value  when 
there  is  fear  of  perforation  through  either  lack  of  vitality  in  the 
bowel  wall,  or  distrust  in  the  method  or  manner  of  suture,  but 
that  as  a  disadvantage  this  method  is  followed  by  tight  and  exten- 
sive adhesions. 

One  more  point  must  be  considered  in  certain  operations  done  to 
restore  the  continuity  of  the  alimentary  canal.  Page^  and  other 
operators  have  lost  their  patients  in  gastro-enterostomy  through 
physiologically  excluding  the  greater  part  of  the  small  intestine, 
the  loop  hooked  up  for  attachment  to  the  stomach  belonging  to  the 
lower  part  of  the  ileum  rather  than  the  upper  part  of  the  jejunum. 
In  these  cases  the  direction  to  seize  the  first  presenting  loop  is 
unsafe — there  should  be  a  careful  search  for  the  upper  part  of  the 
jejunum,  the  fixed  duodenum  being  a  safe  and  sure  guide  to  this 
part  of  the  bowel. 

We  believe  the  greater  majority  of  abdominal  surgeons  now  use 
for  irrigation  simply  hot  distilled  water.  We  have  in  another  place 
given  our  reasons  for  believing  that  the  normal  saline  solution  is 
to  be  preferred.  Against  the  use  of  antiseptic  solutions  strong 
objections  can  be  urged.      If  used  in  efficient  strengths  they  are 

1  London  Lancet,  Mar.  18,  18S9. 


120  WOUNDS    AND    OBSTRUCTION    OF    THE    INTESTINES. 

distinctly  irritating  locally,  and  arc  liable  to  be  followed  by  systemic 
poisoning.  Even  in  weak  solution,  used  as  they  are  in  large  quan- 
tities, dangerous  symptoms  have  resulted.  Thus  Gelli'  reports 
three  cases  where  x^i^ir  bichloride  solution  was  followed  by  the 
appearance  of  toxic  symptoms. 

As  a  result  of  intra-abdominal  injection  it  has  been  found  that 
the  usually  dehydrated  blood  absorbs  at  first  the  injected  liquid 
with  the  greatest  rapidity ;  but  that  soon  becoming  fully  hydrated 
absorption  absolutely  ceases  and  poisonous  injections  may  be  given 
freely  in  so  far  as  the  systemic  eifeet  is  concerned.  The  practical 
bearing  of  this  is  obvious.  If  the  surgeon  wishes  to  use  antiseptics 
in  the  peritoneal  cavity  this  can  be  safely  done  provided  the  cavity 
has  been  previously  flushed  with  water  or  saline  solution.  It  \vould 
seem  then  that  the  following  conclusions  may  be  drawn : — 

1.  Where  there  is  great  tympany  threatening  life,  and  there  is 
reason  to  believe  that  this  is  due  to  a  paretic  state  of  the  bowel 
only,  puncture  and  aspiration  of  gas  under  antiseptic  precaution 
may  be  both  palliative  and  curative.  Certain  cases  of  chronic 
obstruction  are  also  benefited  by  this  procedure.  If  the  bowel  con- 
tracts the  puncture  is  immediately  closed ;  where  paralysis  is  abso- 
lute, however,  leakage  of  feces  may  occur. 

2.  Enterorraphy  is  indicated  in  cases  of  acute  obstruction  where 
tympany  is  marked,  the  vital  poM-ers  are  greatly  enfeebled,  and 
both  the  seat  and  nature  of  obstruction  are  unknown.  When  the 
obstruction  is  in  the  colon  the  opening  should  be  into  the  large  gut. 
This  method  is  both  palliative  and  curative,  relief  of  pressure  being 
frequently  followed  by  spontaneous  restoration  of  the  continuity  of 
the  intestinal  tract. 

3.  Abdominal  section  is  indicated  where  the  abdomen  is  soft,  the 
patient's  condition  fairly  good,  particularly  if  the  seat  and  nature 
of  obstruction  are  indicated.  The  incision  should  be  free,  and  the 
operation  should  very  exceptionally  last  over  thirty  minutes.  Diffi- 
cult and  prolonged  operations  must  give  place  to  formation  of  an 
artificial  anus,  resection  followed  by  end  to  end  suture  being  totally 
unjustifiable.  If  the  patient's  condition  permits  apposition,  im- 
plantation or  invagination  operations  may  be  performed. 

4.  Transplantation  of  omental  flaps  is  followed  by  more  extensive 

'  Aniial  de  Obstetrieia  e  Genecol.,  Nos.  6-7. 


SURGICAL   TREATMENT   OF    INTESTrNAE    OP.STRUCTION.       121 

adhesions  than  where  tliis  ])roee(lnre  is  not  a(lo])ted.  If  antiseptic 
irrigation  is  nsed  the  abdominal  cavity  sliould  be  previously  flushed 
with  sterile  water  or  saline  solution. 

Complications. — We  would  finally  call  attention  to  two  com- 
plications attendant  upon  abdominal  surgery,  and  which  should  be 
considered  in  all  cases  by  the  operator. 

The  first  is  sudden  syncope,  which  may  run  directly  into  death. 
This,  though  rare,  has  been  frequently  observed.  It  is  no  doul)t 
the  cause  of  a  number  of  deaths  placed  to  the  credit  of  ether  or 
chloroform.  By  private  communication  we  have  knowledge  of  two 
such  cases.     From  a  letter  describing  one  we  quote : — 

"■  Spaniard,  man  set.  sixty-five,  scrotal  hernia  of  years'  standing 
retained  by  truss.  Truss  being  broken  patient  worked  without  it 
and  hernia  came  down.  Reduced,  and  man  put  to  bed.  Refused 
to  stay  there,  feeling  perfectly  well.  Gut  again  incarcerated. 
Examination  revealed  a  large  scrotal  rupture  not  tightly  incarce- 
rated, and  showing  no  signs  of  inflammation  or  serious  trouble. 
Taxis  was  resorted  to,  and  after  a  little  manipulation  the  hernia 
was  much  smaller,  when  suddenly  the  patient  moaned  as  if  in  pain, 
and  apparently  fainted.  Examination  showed  that  the  faint  was  in 
reality  the  sleep  of  death.  No  autopsy  was  allowed."  Of  course 
in  this  case  an  injury  to  the  gut  was  possible,  though  not  probable. 
These  deaths  are  commonly  ascribed  to  cardiac  inhibition.  Had 
even  a  few  whiffs  of  ether  been  given  in  this  case  the  anaesthetic 
would  undoubtedly  have  been  considered  as  the  cause  of  the  fatal 
termination. 

The  second  complication,  common  in  all  surgical  operations,  but 
particularly  so  in  abdominal  work,  is  pneumonia.  This  has  fre- 
quently caused  death  where  the  operation  was  perfectly  successful, 
and  has  followed  the  latter  by  weeks  or  even  months.  Both  septic 
and  aseptic  intra-abdominal  operations  are  thus  complicated.  The 
most  obvious  explanation  would  seem  to  be  that  it  is  an  embolic 
process,  yet  this  is  far  from  proven. 

The  knowledge  that  this  inflammation  is  liable  to  develop  should 
lead  the  surgeon  to  avoid  every  possible  exciting  cause,  and  to  be 
ever  watchful  for  its  earliest  symptoms  that  the  treatment  may  be 
inaugurated  before  the  disease  is  fairly  established. 


CHAPTER  XIII. 

WOUNDS    OF   THE    INTESTINES. 

Gunshot  Wounds  of  the  Intestines. — As  in  the  case  of 
gunshot  injuries  of  other  parts,  when  a  bullet  traverses  the  ab- 
clominal  cavity,  it  produces  a  lesion  Avhich  partakes  of  the  nature  of 
a  lacerated  and  contused  wound.  The  peculiarity  of  shot  wounds, 
when  invading  this  portion  of  the  body,  lies  in  the  enormous  pene- 
trating power  of  the  modern  bullet,  and  in  the  close  crowding  of 
the  abdominal  space  with  vital  organs.  The  riile  bullet,  if  it  pene- 
trates the  abdominal  cavity,  almost  certainly  produces  extensive 
visceral  laceration.  This  is  in  marked  contrast  with  the  musket 
balls  of  the  early  part  of  the  century.  Thus  Larrey  and  Baudens 
describe  abdominal  wounds  in  which  the  bullet  has  carried  a  pouch 
of  undershirt  before  it  into  the  peritoneal  cavity ;  by  pulling  upon 
this  garment  the  bullet  was  withdrawn,  not  having  passed  through 
the  fabric.  The  conical  shape  of  the  modern  bullet  also  has  a 
distinct  bearing  upon  the  extent  of  the  injury,  since  a  small  ball 
twisted  sideways  may  inflict  a  larger  and  more  dangerous  wound 
than  a  heavier  ball  passing  point  first.  As  a  matter  of  fact,  how- 
ever, it  is  impossible  to  determine  how  extensively  a  penetrating 
gunsliot  wounds  the  viscera,  since  the  latter  are  not  fixed  in  posi- 
tion, and  a  small  ball  passing  parallel  to  the  long  axis  of  a  bowel 
loop  may  tear  an  opening  into  it  two  or  three  inches  in  length. 

In  the  United  States  Army  the  standard  rifle  carries  a  ball 
yYtt  ii3ch  in  diameter,  and  weighing  500  grains.  It  is  pro- 
pelled by  70  grains  of  powder.  Abdominal  wounds  inflicted  by 
this  weapon  are  now  exceedingly  rare,  and  would  necessarily  be 
attended  with  a  very  great  mortality.  In  the  Civil  War  the  bullet 
used  weighed  500  grains,  and  was  half  an  inch  in  diameter.  It 
seems  scarcely  possible  that  this  large  elongated  mass  of  lead,  driven 
through  and  through  the  peritoneal  cavity,  could  escape  inflicting 
mortal  wounds,  yet  that  this  has  happened  is  attested  by  the  Sur- 
geon-General's   report.     Such    injuries    are   obviously    not   to    be 


WOUNDS    OF   THE    INTBSTINP]8.  123 

classed  with  those  occurring  in  (sivil  ]>ra(;ticc,  wlicre  tlio  (liuni(;tor 
of  tlie  ball  is  frequently  but  -^-^-^  inch,  and  its  weight  GO  grains. 
Much  larger  balls  are  used,  ^-^-^  calibre  j)erhaps  being  the  common 
size.  We  have  in  our  tables  instances  of  No.  38  and  No.  44  re- 
volvers having  been  used  at  close  range.  These  would,  of  course, 
inflict  as  much  injury  as  the  rifle  ball. 

The  first  thing  to  consider  in  dealing  with  gunshot  wounds  oi 
the  abdomen  is  as  to  whether  or  not  the  bullet  has  pierced  the 
parietal  peritoneum.  This,  which  would  seem  an  easy  problem  at 
first  glance,  is  in  reality  one  which  is  difficult  to  solve.  We  have 
seen  two  penetrating  gunshot  wounds,  inflicted  by  a  f\^^-g-  ball,  and 
from  which  the  patient  shortly  perished,  thwart  every  effi^rt  of  the 
operator  to  follow  with  the  finger  or  probe  .the  course  of  the  vul- 
neratiug  body.  In  experimental  work  upon  dogs  we  have  in  the 
majority  of  instances  not  succeeded  in  passing  a  probe  along  the 
track  of  the  ball  into  the  peritoneal  cavity. 

In  deciding  as  to  peneti'ation,  certain  facts  will  materially  aid 
the  surgeon.  First  must  be  considered  the  size  and  length  of  the 
cartridge.  A  Flobert  cap  or  a  22  short,  may  not  have  sufficient 
force  to  penetrate  the  clothing  and  the  abdominal  wall ;  the  bullet 
of  a  larger  cartridge  will  almost  certainly  penetrate  if  its  course  is 
straight. 

The  distance  from  which  the  ball  was  fired,  the  direction  from 
which  it  came,  the  position  of  the  wounded  man  when  struck,  are 
all  important  matters.  The  possibility  of  the  ball  being  deflected 
by  a  button  or  by  any  foreign  body  in  the  pocket,  or,  after  it  has 
penetrated  into  the  body,  by  bony  prominences,  must  also  be  con- 
sidered. McGraw  claims  that  balls  are  not  deflected  by  soft  parts, 
but  against  this  is  the  record  of  well  authenticated  cases.  In  our 
own  experiments  (20  in  number),  the  ball  was  deflected  in  but  one 
instance.  It  was  fired  from  a  distance  of  ten  feet,  in  a  direction 
downward,  and  at  right  angles  to  the  long  axis  of  the  dog.  It 
passed  in  (calibre  22)  upon  the  left  side,  half  an  inch  below  the 
rib  margin,  and  one  and  a  half  inches  to  the  left  of  the  nipple  line. 
It  perforated  the  colon,  made  four  wounds  in  the  ileum,  two  in  the 
cfecum,  and  lodged  in  the  pelvis  of  the  right  side,  a  deflection  of 
fully  four  inches.  It  struck  against  no  bony  part,  nor  were  there 
hardened  feces  which  misht  have  turned  it  from  its  course.     This 


124  WOUNDS    AND    OBSTRUCTION   OF   THE    INTESTINES. 

positive  evidence  is,  of  course,  fur  more  conclusive  than  many  nega- 
tive experiments. 

As  a  rule,  and  as  general  in  application  as  the  one  which  states 
that  all  penetrating  wounds  of  this  class  are  attended  with  visceral 
injury,  it  may  be  stated  that  the  course  of  the  bullet  is  a  straight 
one.  The  application  of  this  rule  would  be  of  very  great  practical 
value  to  surgeons,  but  for  one  circumstance.  To  determine  the 
track  of  the  ball  the  surgeon  nuist  knoM'  the  direction  from  which 
it  was  fired,  and  the  exact  position  of  the  wounded  person  when 
struck.  This  information,  in  the  majority  of  cases,  cannot  be  ob- 
tained. We  can  determine  that  the  injury  was  inflicted  from  in 
front,  or  from  the  side,  but  rarely  can  eye-witnesses  or  the  patient 
himself  tell  us  whether  or  not  he  was  rising  from  his  chair,  was 
vStooping  forward,  was  twisted  sideways,  was  running,  or  was  mak- 
ing any  violent  muscular  effort.  The  shape  of  the  wound  some- 
times suggests  the  direction  from  which  the  ball  has  come,  the 
surface  impact  making  either  a  clear  cut  hole  or  a  grooved  or  con- 
tused track,  depending  upon  whether  the  ball  is  received  from  the 
front  or  strikes  obliquely. 

It  may  generally  be  accepted  foi*  granted  that  a  ball  from  any 
revolver,  with  greater  penetrating  power  than  that  given  from  the 
22  short  cartridge,  which  has  struck  the  abdomen  squarely  from 
the  front,  has  penetrated  into  the  peritoneal  cavity.  As  positive 
knowledge  upon  this  point  is  of  cardinal  importance,  the  value 
of  the  information  thus  gained  constitutes  a  sufficient  excuse  for 
both  probing  and  digital  exploration  under  rigid  antiseptic  precau- 
tions. If,  after  this  method  of  examination,  the  surgeon  is  still 
in  the  dark,  we  can  see  no  objection  to  carefully  following  up  the 
ball  track  by  incisions.  In  case  of  non-penetration  the  original 
wound  has  not  been  seriously  complicated.  If  the  abdominal  cavity 
is  entered,  the  surgeon's  finger  arrives  at  the  point  where  the  signs 
of  serious  visceral  wounds  are  most  likely  to  be  manifested. 

The  diagnosis  of  penetration  having  been  made  the  question  as 
to  whether  or  not  serious  visceral  lesions  have  resulted  becomes 
one  of  prime  importance.  In  every  one  of  our  experiments  a 
penetrating  gunshot  wound  was  followed  by  wound  of  the  ab- 
dominal contents.  In  our  appended  tables  but  four  cases  were, 
upon  section,  found  to  have  no  internal  injury. 

When  we  speak  of  the  abdominal  cavity  it  must  be  borne  in  mind 


WOUNDS   OF   THE    INTESTINES.  125 

that  this  space  is  absoUitcly  and  entirely  filled  with  important  organs. 
There  are  no  interstices  or  spaces  in  whieli  nothing  is  placed.  Each 
viscus  is  accurately  packed,  and  is  kept  in  close  apposition  under 
alterations  in  size,  by  the  ever  changing  tension  of  the  belly  walls. 
Hence  even  the  slightest  penetration  of  the  peritoneal  cavity,  by  a 
missile  travelling  with  the  velocity  of  a  bullet,  will  almost  certainly 
result  in  injury  to  the  contained  organs.  It  can  be  assumed,  then, 
as  a  working  rule,  that  every  penetrating  wound  of  the  aljdomen 
has  produced  more  or  less  serious  visceral  lesion.  On  the  basis 
that  certain  eases  which  recover  without  serious  symptoms  after 
penetrating  or  perforating  gunshot  wounds  of  the  belly  recover, 
because  there  are  no  visceral  lesions,  the  percentage  of  wounds 
entering  the  abdominal  cavity  without  wounding  the  viscera  is  fre- 
quently stated  to  be  ten  in  the  hundred.  We  shall  presently  show 
that  statistics  founded  upon  this  estimation  are  not  reliable,  since 
patients  do  frequently  recover  from  these  injuries  even  though 
there  may  have  been  multiple  and  extensive  visceral  lesions.  Our 
own  figures  show  that  the  percentage  of  penetration  without 
visceral  wound  is  about  S^  per  cent. 

As  a  second  proposition  it  may  be  stated  that  the  lesion  inflicted 
by  a  penetrating  gunshot  wound  of  the  abdomen,  especially  if  the 
ball  has  passed  through  and  through,  is  multiple. 

Since  it  is  especially  with  intestinal  wounds  that  we  have  to  deal 
in  this  paper,  it  is  next  in  order  to  study  the  pathological  changes 
which  occur  in  a  portion  of  the  gut  lacerated  by  a  pistol  ball. 
The  first  effect  is  to  produce  a  local  spasm,  so  marked  that  Bau- 
dens^  used  it  in  his  digital  intra-abdominal  search,  as  a  diagnostic 
point.  Immediately,  consequent  upon  muscular  contraction,  there 
is  an  eversion  of  the  loose  mucous  coat  of  the  bowel,  sufficient  to 
entirely  occlude  even  comparatively  large  wounds.  Following  the 
spasmodic  contraction  the  involved  portion  of  the  gut  becomes 
paretic,  absolutely  losing  all  peristaltic  motion.  Beck^  observes 
that  in  his  vivisection  experiments,  so  long  as  the  healing  can  be 
delayed  by  peristalsis  the  animal  instinctively  refuses  all  food. 
This  paralysis  is  not  so  absolute  but  that  purgatives,  or  even  the 
irritation  of  the  ordinary  ingesta  may  overcome  it.     It  is  sufficient, 

1  Cliniqne  des  Plaies  d'Armes  a  Feu. 

2  Schusswuiuieii,  Heidelberg,  1S49. 


126  WOUNDS   AND   OBSTRUCTION   OF   THE   INTESTINES. 

however,  to  splint  small  wounds  until  they  can  be  tightly  closed  in 
the  further  process  of  healing. 

The  next  step  in  the  process  is  the  effusion  and  organization  of 
plastic  lymph.  This  may  simply  envelop  the  seat  of  trauma,  or, 
and  tliis  is  much  more  common,  may  serve  as  an  organizable  glue 
for  the  purpose  of  tightly  apposing  healthy  omentum  or  peritoneal 
surface  to  the  bowel  wound  temporarily  closed  by  prolapsed  mucous 
membrane.  At  times  the  omentum  enters  as  a  cork  through  the 
wound  into  the  bowel  lumen,  and  is  secured  in  this  position  by 
rapid  adhesive  inflammation.  The  opening  is  frequently  closed  by 
neighboring  intestinal  loops  which  act  as  temporary  occluders. 
Subsequent  cicatrization  of  the  effused  plastic  lymph  accomplishes 
the  permanent  healing  of  bowel  wounds.  By  the  constant  peri- 
stalsis adhesions  may  subsequently  be  drawn  out  into  bands;  more 
frequently  they  entirely  disappear.  Jobert  claimed  that,  although 
the  muscular  contraction  and  mucous  membrane  prolapse  prevented 
the  escape  of  feces,  gas  nearly  always  passed  out  through  a  bowel 
wound,  and  by  the  immediate  resultant  tympany  gave  rise  to  a 
pathogenic  symptom  of  this  form  of  injury.  It  is  recognized  now 
that  the  closing  which  nature  spontaneously  effects  is  sufficient  to 
retain  both  gas  and  feces.  Even  though  the  latter  escape  in  small 
quantity  there  is  still  a  method  of  cure.  By  plastic  inflammation 
the  extravasation  can  be  shut  off  from  the  general  peritoneal  cavity, 
and  the  resultant  abscess  may  gradually  work  its  way  to  the  surface, 
generally  through  the  track  of  the  wounding  body. 

Although  it  is  true  that  even  very  small  wounds  may  be  followed 
by  fecal  extravasation,  it  should  be  well  recognized  that  this  com- 
plication is  an  exception  rather  than  a  rule.  Even  though  the 
intestinal  walls  be  torn,  since  there  is  in  reality  no  cavity  into 
which  the  bowel  contents  can  be  poured  there  is  no  natural  ten- 
dency for  extravasation  to  take  place.  If  the  bowels  are  inflated 
with  gas,  this,  diffusing  itself  in  all  directions,  may  create  space  by 
passing  into  the  general  peritoneal  cavity  and  pushing  out  the 
abdominal  walls.  Consequently  when  there  is  escape  of  intestinal 
gas,  this  is,  as  a  rule,  followed  by  fecal  extravasation.  This  acci- 
dent is  of  course  far  more  likely  to  occur  if  the  bowels  are  full, 

Vastin^  mentions  a  case  where  the  bowel  was  completely  torn 
across  in  two  places,  yet  there  was  no  fecal  extravasation.     Archer^ 

1  Craig.  Franc  de  Cherin,  1888.  2  N.  Y.  Med.  Jour.,  vol.  15,  p.  215. 


WOUNDS    OF   THE    INTESTINES.  127 

reports  an  instance  where,  tlirongh  a  two-inch  wound  of  tlie  stomaf!li 
the  patient's  dinner  was  discharged,  a  jjortion  passing  into  the 
general  peritoneal  cavity.  Nine  days  later  there  was  suppuration 
in  the  groin.  On  evacuation  of  the  abscess,  pus  and  cabbage  were 
discharged.     The  patient  recovered. 

The  natural  tendency  of  extravasation  is  to  escape  through  the 
external  wound,  since  in  this  direction  only  is  the  space  not  already 
filled.  Guthrie  notes  this,  and  states  that  when  the  visceral  con- 
tents are  poured  out  through  a  small  external  wound,  the  latter 
should  be  enlarged,  the  gut  wound  being  sutured. 

As  a  result  of  extensive  extravasation,  excepting  when  the 
external  wound  gives  free  exit,  a  fatal  peritonitis  is  nearly  always 
developed.  This  is  the  most  dreaded  of  all  complications  and  ter- 
minates with  the  life  of  the  patient  in  from  twenty  to  forty-eight 
hours.  It  is  not,  however,  the  general,  or  even  the  usual  result  of 
abdominal  gunshot  Avounds.  In  a  record  of  127  cases  we  found 
fecal  extravasation  mentioned  in  but  16  instances,  giving  a  ratio  of 
12  per  cent. 

A  very  frequent  complication,  and  one  which  is  responsible  for 
the  great  majority  of  deaths  occurring  very  shortly  after  the  wound, 
is  internal  bleeding.  We  found,  in  our  experiraeuts,  that  sixty 
per  cent,  of  the  dogs  shot  through  the  belly  died  within  the  hour 
of  hemorrhage,  or  would  have  died  had  not  the  bleeding  points 
been  secured. 

In  our  statistics  we  find  thirty-three  per  cent,  of  cases  in  which 
internal  bleeding  was  a- grave  complication.  We  know  of  no  source 
frjm  which  may  be  determined  the  number  of  fatal  cases  due  to  this 
cause.  Even  in  surgical  war  records,  complete  in  other  respects,  the 
whole  number  lost  in  battle  is  simply  classed  as  killed.  As  seen, 
abdominal  hemorrhage  results  fatally  in  a  few  hours.  It  is  impos- 
sible to  say  how  great  a  proportion  perish  from  the  wounding  of 
important  bloodvessels. 

It  is  claimed  by  many  surgeons  that  the  shock,  which  is  such 
a  frequent  complication  of  intestinal  wounds,  is  never  present, 
except  as  a  symptom  of  internal  bleeding.  This  view  cannot 
stand  under  careful  examination,  since  there  are  many  cases  re- 
ported in  which  subsequent  examination  showed  there  was  no 
bleeding,  and  yet  in  which  shock  was  so  profound  as  to  threaten 
death.     The  symptoms  of  hemorrhage  into  the  abdominal  cavity 


128  WOUXDS    AND    OBSTRUCTION    OF   THE ,  INTESTINES. 

do  not  differ  from  those  dependent  on  bleeding  in  any  other  part  of 
the  body.  The  same  disorders  of  respiration,  of  sensation,  and  of 
heart  action,  are  to  be  noted.  lu  addition  there  are  certain  local 
signs  which  are  of  great  value  to  tlie  surgeon.  Increasing  dulness 
of  the  flanks,  with  deepening  shock,  particularly  if  associated  with 
the  desire  to  urinate  frequently,  would  be  almost  pathognomonic  of 
this  complication. 

To  this  bladder  condition  Baudens  has  called  attention,  stating 
that  when  there  is  much  blood  gravitating  into  the  pelvis,  there  is 
a  constant  insupportable  desire  to  urinate,  due  to  the  mechanical 
pressure.  Of  course  if  the  hemorrhage  be  slight  in  amount  it 
may  be  entirely  circumscribed,  ultimately  being  either  absorbed, 
or  breaking  down,  and  discharging  as  an  abscess.  Where  the 
bleeding  is  free  it  inevitably  gravitates  into  the  pelvis  and  dependent 
parts. 

Shock  is  a  condition  which  very  commonly  accompanies  intes- 
tinal wounds ;  some  surgeons  cons.der  it  of  diagnostic  value,  the 
amount  of  shock  denoting  the  intensity  of  intra-abdominal  injury. 
That  patients,  suffering  from  gunshot  Avound  of  the  abdomen,  are 
profoundly  shocked,  or  even  collapsed,  from  the  very  beginning, 
cannot  be  doubted,  but  it  is  found  that  this  condition  depends  more 
upon  individual  peculiarities  than  the  actual  amount  of  injury,  and 
that  it  is  impossible  to  differentiate  these  symptoms  from  those 
characterizing  bleeding.  Our  tables  show  many  instances  of  most 
extensive  wounds,  where  the  shock  was  slight  or  wanting,  and  we 
have  repeatedly  seen  burly  men  suffering  from  a  light  flesh  wound, 
exhibit  temporarily,  all  the  symptoms  of  profound  shock. 

It  is  most  important  to  determine  whether  the  patient  suffers 
from  shock  or  internal  bleeding,  since  the  treatment  for  bleeding- 
is  immediate  operation,  while  the  treatment  for  shock  is,  of  course, 
quite  the  reverse.  It  is  certainly  true  that  many  of  the  cases,  in 
which  shock  has  been  most  profound,  have  been  found  to  be  suffer- 
ing from  internal  hemorrhage  ;  where  the  shock  is  prolonged  and 
steadily  deepening,  even  in  the  absence  of  other  symptoms  it  is 
perhaps  safest  to  act  as  though  a  diagnosis  of  hemorrhage  had 
been  made. 

We  think  we  have  discovered  a  means  by  which  this  differentia- 
tion possibly  may  be  determined,  not  under  all  circumstances,  it  is 
true,  but  Avith  sufficient  frequency  to  be  of  value  to  the  surgeon. 


WOUNDS   OF   THE   INTESTINES.  129 

The  effect  of  rapid  or  prolonged  hemorrhage  upon  tlie  eonijiosition 
of  the  blood  is  well  known  ;  such  patients  will  be  found  to  exhibit 
deficient  haenioglobin,  and  the  corpuscular  count  will  be  low.  We 
have  made  several  observations  on  the  human  to  determine  whether 
or  not  this  condition  is  sufficiently  constant  to  be  of  clinical  value. 
We  find  that,  with  certain  limitations,  the  percentage  of  hiemoglobin 
is  a  fairly  accurate  guide  as  to  the  amount  of  blood  lost.  Tliis  test 
may  be  made  in  two  minutes.  Of  course  it  is  impossible  to  know 
what  the  normal  for  each  individual  may  be.  Blight  variations 
will  be  of  no  consequence,  but  serious  bleeding  so  profoundly 
affects  the  blood  that  the  haemoglobin  will  necessarily  show  a  dimi- 
nution far  below  the  line  of  individual  peculiarity.  Thus,  in  case 
of  tumor  in  the  neck,  upon  which  an  operation  was  performed,  and 
in  which  there  was  much  bleeding,  the  symptoms  of  hemorrhage 
were  slightly  marked,  hsemoglobin  count  giving  seventy-five  per 
cent.  In  a  case  struck  by  a  locomotive,  and  very  profoundly- 
shocked,  temperature  96,  pulse  138,  the  hsemoglobin  was  over  100.. 
In  a  case  lacerated  by  car  wheels,  the  right  leg  and  arm  haiving 
been  torn  off,  and  in  which  it  was  alleged  there  had  been  no  blieed-- 
ing,  there  was  thirty-eight  per  cent,  of  hsemoglobin,  showiiig:  that 
the  statements  of  those  around  this  patient  were  not  true. 

The  only  instance  where  this  test  failed  was  in  a  case  of  severe 
shock  from  spinal  injury.  The  temperature  was  96|,  the  pulse  80, 
the  respiration  30.  The  man  was  very  pale.  Capillaries  seemed 
empty,  there  was  much  difficulty  in  obtaining  blood.  Haemoglobin 
seventy-eight  per  cent.  In  this  ease  other  symptoms  sufficiently 
excluded  severe  hemorrhage. 

In  instances  where  patients  suffering  from  abdominal  wounds 
exhibit  the  characteristic  symptoms  of  either  hemorrhage  or  shock, 
we  think  the  hsemoglobinometer  may  aid  in  determining  which  of 
the  two  conditions  is  really  present. 

Diagnosis. — We  have  alluded  to  the  difficulty  of  determining 
whether  or  not  a  ball  has  penetrated  the  abdominal  cavity.  The 
question  of  deciding  as  to  the  presence  of  one  or  more  severe  lesions 
of  the  abdominal  contents  is  still  more  complicated. 

As  a  general  rule  it  is  safe  to  assume  that  such  lesions  have 
occurred,  but  it  is  of  extreme  importance  to  the  patient  to  be  able 
to  recognize  the  exceptions.     To  those  who  hold  that  visceral  injmy 


130  AVOUNDS   AND   OBSTRUCTION    OF   THE   INTESTINES. 

is  necessarily  accompanied  by  shock,  the  distinction  would  be  easy, 
but  to  the  modern  surgeon  experienced  in  these  cases  or  well  read 
in  the  literature  of  to-day,  a  diagnosis  is  impossible. 

Certain  symptoms  are  classical,  as  characterizing  bowel  lesions. 
Either  fecal  extravasation  or  the  escape  of  gas  through  the  external 
wound  would  positively  denote  that  the  alimentary  tract  had  been 
opened,  but  in  the  absence  of  these  two  signs,  and  they  are  both  as 
a  rule  absent,  there  is  absolutely  nothing  which  can  be  always  relied 
upon  in  making  a  diagnosis  of  this  injury. 

It  is  true  that  bloody  vomit  suggests  a  wound  in  the  stomach, 
yet  Me  know  the  symptoms  may  occur,  although  the  stomach  has 
not  been  opened.  Thus  a  ball  may  produce  simply  a  contusion, 
with  the  resultant  rupture  of  bloodvessels  of  the  mucous  membrane 
and  hsematemesis ;  the  same  is  true  in  regard  to  the  evacuation 
of  blood  from  the  bowels. 

Blood  in  the  passages  is  extremely  suggestive  of  a  wound  of  the 
large  intestine,  if  this  blood  be  partially  digested  it  has  been  proba- 
bly eifused  from  the  small  intestine,  yet  this  symptom  may  be 
present  without  penetration  of  the  bowel,  and  may  be  absent  though 
there  be  multiple  lesions  of  the  digestive  tube. 

Prompt  meteorism  was  considered  by  older  surgeons  to  be  of 
peculiar  value  in  making  a  diagnosis.  Jobert  ascribed  this  phe- 
nomenon to  the  escape  of  intestinal  gas  from  the  bowel  wound. 
This  is'  not  reliable,  since  many  cases  may  run  to  a  fatal  termina- 
tion and  never  exhibit  this  symptom ;  and  simple  contusion  of  the 
belly  walls  often  produces  extreme  distention.  Though  as  a  general 
rule  it  is  true  that  the  belly  does  become  tympanitic  after  pene- 
trating wounds,  it  is  due  more  commonly  to  intestinal  2)aralysis, 
than  to  escape  of  gas  into  the  general  peritoneal  cavity. 

The  direction  of  the  ball,  the  shape  of  the  orifice,  the  wound  of 
exit,  if  it  is  present,  the  presence  of  blood  in  vomit  or  feces,  the 
position  of  the  patient  when  injured,  the  constitutional  condition, 
pain,  all  must  be  carefully  examined  into,  as  all  these  points  con- 
tribute to  a  diagnosis.  Even  after  a  most  extensive  examination 
of  symptoms,  however,  it  must  be  confessed  that  there  is  but  one 
way  to  determine  the  presence  or  absence  of  bowel  wounds,  and 
that  is  by  opening  the  abdominal  walls  and  searching  with  eye 
and  finger.  Stimson  says  that  exploration  is  justifiable  in  every 
case  of  doubtful  penetration.     Baudens  advises  seai'ching  for  the 


WOUNDS   OF   THE   INTESTINES.  131 

wound.  Chauvel  states  that  every  penetrating  wound  of  the  al)- 
donien  by  wea})on  of  small  calibre,  with  probable  vascular  or 
visceral  lesions,  requires  exploratory  examination  of  the  wound. 

Baudeus  states  that  the  intestinal  wounds  are  almost  always  seated 
behind  the  abdominal  opening ;  hence,  if  there  is  any  injury  to  tlic 
gut,  enlargement  of  the  peritoneal  wound  -will  probably  successfully 
demonstrate  it;  if  not,  the  finger  should  be  carried  into  the  peritoneal 
cavity  in  search  of  blood  or  feces,  or  even  a  sponge  may  be  thrust 
down  through  the  intestinal  loops  to  the  dependent  portions  of  the 
abdominal  cavity.  After  such  an  examination,  if  no  hardening  of 
the  gut,  no  feces,  no  blood,  and  no  bubbles  of  gas  are  discovered, 
there  is  either  no  wound  or  one  with  which  nature  can  cope. 

Prognosis. — This  is  unfortunately  bad,  and  under  any  form  of 
treatment  the  chances  of  recovery  for  a  patient  who  suiFers  from  a 
penetrating  gunshot  wound  of  the  abdomen  are  not  good.  In 
military  surgery  there  can  be  no  question  but  that  the  vast  majority 
of  these  cases  perish  on  the  field.  Beck  remarks,  "  I  have  never  seen 
any  hospital  patients  suffering  from  wounds  of  either  the  small  or 
large  intestine."  In  all,  death  came  quickly.  Otis  gives  the 
mortality  of  penetrating  abdominal  wounds,  as  shown  in  our  Civil 
War,  as  87  per  cent.  He  states  that  a  great  number  of  recoveries 
were  those  in  which  the  large  intestine  w^as  wounded  in  one  of  its 
portions  not  covered  by  peritoneum,  the  cure  being  frequently 
complicated  by  the  formation  of  an  artificial  anus.  Cases  of  re- 
covery where  the  solid  or  membranous  viscera  are  wounded,  with 
extravasation  of  their  contents  within  the  peritoneal  cavity,  Otis 
considers  so  rare  that  well  authenticated  examples  can  be  counted 
on  the  fingers,  while  penetration  of  the  peritoneal  cavity  without 
wound  of  its  contents  is  nearly  as  rare.  Gurlt  states  that  in  the 
Franco-German  War  of  227  cases  of  penetrating  wound  of  the 
abdomen  59  recovered,  148  died  and  22  were  unaccounted  for. 
In  this  last  class  it  is  possible  that  at  least  the  majority  recovered. 
Leaving  them  entirely  out  of  the  question,  however,  this  would 
give  a  mortality  of  about  72  per  cent.  In  the  Crimean  War  10 
per  cent,  of  cases  were  said  to  have  recovered.  In  the  Franco- 
Italian-Austrian  War  34  per  cent.  The  Franco-German  War  has 
shown  a  still  larger  percentage  of  recoveries  (Chenu). 

Nimier  "gives  out  of  5003  cases,  a  mortality  of  80  per  100." 


132  WOUNDS   AND   OBSTRUCTION   OF   THE   INTESTINES. 

In  all  these  statistics,  differing  so  widely  in  their  results,  the  mor- 
tality is  probably  understated. 

The  only  efforts  at  tabulating  the  result  of  gunshot  wounds  as 
inflicted  in  time  of  peace  by  weapons  of  small  calibre,  and  not 
treated  by  operatiye  interference  are  first  that  made  by  Stimson, 
who  places  the  mortality  at  65  per  cent. ;  next  the  records  of 
Reclus  and  Nogues,  who  in  a  total  of  88  cases  note  a  mortality  of 
25  per  cent. 

Against  this  last  compilation  must  be  urged,  the  objection  which 
is  applicable  to  all  tabulations  from  reported  cases.  Hundreds  of 
gunshot  wounds  terminating  fatally  are  not  reported  by  physicians 
simply  because  this  termination  is  what  is  to  be  expected,  and 
without  interest  to  the  medical  reader.  If,  howeyer,  there  is  clear 
eyidence  that  a  ball  has  penetrated  the  peritoneal  cayity,  and  in 
spite  of  this  the  patient  subsequently  recoyers,  the  case  becomes 
one  of  great  interest  and  rarely  escapes  becoming  a  part  of  current 
medical  literature.  Hence  the  rate  of  mortality  giyen  by  such  a 
table  is  far  too  fayorable. 

Against  Stimson's  table  it  must  be  urged  that  the  diagnosis  of 
penetration  was  not  positiyely  made,  he  eliminated,  howeyer,  many 
cases  terminating  fayorably,  in  which  there  was  no  symptom 
beyond  penetration  to  proye  intestinal  wound.  It  has  been  shown 
that  such  cases  may  recoyer  in  spite  of  multiple  intestinal  injury, 
hence  we  belieye  Stimson's  figures  represent  more  fairly  the  general 
result  to  be  looked  for  from  expectant  treatment  in  wounds  such  as 
are  ordinarily  inflicted  in  centres  of  population,  than  any  other  com- 
pilation "that  has  yet  appeared.  The  same  is  undoubtedly  true  of  his 
table  upon  abdominal  section,  to  which  we  shall  later  make  reference. 

Reclus  and  Nogues  haye  included  in  their  tables  mainly  such 
cases  as  give  positive  evidence  of  penetration  with  visceral  wound. 
These  cases  they  divide  into  three  classes.  The  first  comprising  six, 
three  of  whom  recovered,  represent  cases  where  an  autopsy  con- 
firmed the  diagnosis  of  intestinal  wounds,  with,  in  the  recovered 
cases,  complete  cicatrization.  The  second  includes  56  cases,  in  all 
of  which  blood  from  the  mouth  or  anus,  or  fecal  extravasation 
evidenced  visceral  wound  ;  44  of  these  survived.  The  third  class, 
numbering  26,  comprises  cases  w^here  visceral  lesion  is  made  proba- 
ble only  by  the  fact  of  penetration;  19  of  these  recovered. 

This  gives  a  general  mortality  of  twenty-five  per  cent.     We 


WOUNDS    OF   THE    INTESTINES.  133 

have  already  given  reasons  for  believing  that  it  is  by  no  means 
representative  of  the  true  mortality  in  these  cases. 

Otis  and  many  surgeons  grant  that  wounds  of  the  large  intestine 
may  heal,  but  are  inclined  to  reject  the  possibility  of  this  termina- 
tion in  wounds  of  the  small  intestines.  Our  table  shows  that  of 
130  cases  of  abdominal  wound,  in  48  the  small  intestines  only  were 
wounded.  In  4  the  stomach  only  was  wounded,  in  8  the  colon 
only.  Unless  the  bullet  enters  antero-posteriorly  in  the  lumbar 
region,  no  surgeon  can  say  that  the  large  intestine  only  has  been 
injured,  since  siiot  wounds  are  nearly  always  multiple  and  the  small 
intestine  is  commonly  involved ;  still  there  is  an  almost  universal 
belief  in  the  greater  mortalitv  of  wounds  of  the  lesser  bowel.  This 
is  perhaps  owing  to  its  more  fluid  contents,  and  greater  mobility. 
Our  statistics  show  that  of  48  wounds  of  the  small  intestines  only, 
36  (75  per  cent.)  died ;  while  of  8  wounds  of  the  large  intestine 
only,  5  died,  giving  a  mortality  of  62.5  per  cent.  Of  course  it 
must  be  remembered  that  the  small  intestine  wounds  were  usually 
multiple,  while  those  of  the  colon  were  single,  or  at  most  through 
and  through. 

Treatment. — As  in  the  treatment  of  obstruction,  the  opinion 
of  medical  men  is  divided  between  expectant  treatment  and  opera- 
tive intervention.  Just  now  a  great  wave  of  surgical  ardor  has 
swept  over  our  country,  and  the  almost  unanimous  opinion  seems 
to  be  that  since  these  wounds  usually  penetrate,  usually  injure  the 
viscera,  and  that  when  this  occurs  death  is  the  rule,  the  first  resort 
of  the  surgeon  should  be  a  formal  section,  with  the  idea,  primarily, 
of  determining  whether  or  not  the  ball  has  entered  the  peritoneal 
cavity,  next  to  find  the  seats  of  lesion,  and  apply  to  them  the  proper 
surgical  treatment. 

The  advocates  of  this  treatment  have  pointed  with  much  pride  to 
the  statistical  record  of  cases  operated  upon,  and  of  those  treated 
expectantly.  As  types  of  the  former  they  have  taken  patients 
wounded  by  weapons  of  small  calibre,  and  in  cases  where  medical 
aid  was  promptly  rendered,  comparing  these  results  with  those 
obtained  when  the  wound  was  by  a  large  musket  ball,  and  was 
inflicted  many  hours  before  the  patient  could  have  the  benefit  of 
professional  assistance.  Because  the  results  of  operation  have  been 
slightly  better  than  those  following  non-operative  treatment  under 


134  WOUNDS    AND    OBSTRUCTION    OF    THE    INTESTINES. 

tlic  circuiiistanccs  described,  it  1ms  beeu  held  that  these  figures  con- 
stitute au  absolute  justification  for  the  use  of  the  knife.  It  is  certain 
that  not  only  is  such  a  comparison  unfair  from  the  very  nature  of 
the  two  series  of  cases,  but  also  because  the  tables  compiled  from 
reported  cases  are  absolutely  misleading.  Stimson  has  given  most 
positive  proof  of  this  fact  in  his  analysis  of  the  operative  treatment 
of  these  cases  in  the  city  of  New  York.  Whereas,  for  the  purposes 
of  the  statistician,  there  were  on  record  1 2  cases  of  section,  with  4 
recoveries,  giving  a  moi'tality  of  66|  per  cent.,  in  reality  there  have 
been  31  operations  performed,  of  which  25  resulted  in  death,  thus 
raising  the  mortality  to  80.6  per  cent.  Applying  these  figures  to 
the  general  tables,  our  own  for  instance,  it  will  be  seen  that  for 
purposes  of  com])arison,  the  latter  are  of  little  value.  A  comparison 
of  cases  treated  by  operation  with  those  treated  expectantly,  in  two 
hospitals  in  New  York,  each  set  of  cases  being  under  the  charge 
of  men  prominent  for  their  skill,  gave  about  the  same  mortality  for 
each  method  of  treatment. 

From  a  statistical  point  of  view  Stimson's  paper  is  undoubtedly 
the  most  powerful  argument  yet  advanced  against  formal  section 
as  a  routine  treatment  for  intestinal  gunshot  wounds.  The  vari- 
ous objections  to  this  procedure  have  been  most  ably  collated  by 
Reclus  and  Nogues  who,  as  the  result  of  a  careful  examination  into 
statistics  and  after  a  certain  amount  of  experience  in  these  cases, 
formulate  their  ideas  in  the  following  words : — 

"  In  the  present  state  of  science,  we  believe  that  systematic 
abstention  is  less  murderous  than  laparotomy."  "  By  probing  of 
the  wound,  introduction  of  the  aseptic  finger  preceded  by  enlarge- 
ment if  necessary,  we  can  determine  whether  or  not  the  peritoneum 
is  opened.  From  this  we  decide  as  to  whether  the  wound  is  in  the 
stomach  or  intestine.  We  close  the  external  wound  by  a  pledget 
of  iodoform  and  collodion,  uniformly  compress  the  abdomen  by 
bandage,  use  morphia  hypodermically,  insist  upon  abstention  from 
food,  and  by  the  mouth  give  only  a  few  coffee  spoonfuls  of  iced 
milk.  Under  this  method  we  have  had  three  successes  from 
penetrating  wounds  by  revolver  balls." 

It  is  certainly  true  that  the  vast  bulk  of  the  profession  favor 
immediate  abdominal  section  and  there  can  be  no  question  but  that 
this  procedure  has  many  times  saved  lives  which  would  otherwise 
have  been-  lost ;  but  it  must  be  carefully  considered  whether  inter- 


SUEGICAL   TEEATMEKT    OF    INTESTINAL    OBSTRUCTION.        135 

vention  saves  more  lives  than  can  be  preserved  by  non-snrgical 
treatment. 

A  very  brief  pernsal  of  our  tables  will  show  that  the  many 
deaths  occur  so  sliortly  after  laparotomy  tliat  the  inference  as  to 
this  being  the  direct  causative  agent  is  most  direct.  It  is  clearly 
recognized  that  the  success  of  operation  diminishes  in  proportion 
to  the  time  intervening  between  the  infliction  of  the  wound  and 
surgical  interference.  Trelat  states  that  after  twenty-four  hours  the 
operation  is  practically  fatal,  and  that  septic  peritonitis  is  the  most 
frequent  cause  of  death. 

An  examination  of  the  reported  cases  shows  that  hemorrhage, 
shock,  and  collapse  must  take  the  place  of  prime  importance  in 
case  of  death  within  twenty-four  hours  of  operation. 

We  believe  that  the  advice  given  by  Baudens  fifty  years  ago  is 
still  in  advance  of  the  latest  surgery  of  the  day.  His  counsel  is 
neither  for  formal  abdominal  section  nor  for  abstention.  Believ- 
ing, as  he  did,  that  practically  all  penetrating  gunshot  wounds  of 
the  abdominal  cavity  wounded  viscera,  but  that  these  wounds  were 
capable  of  spontaneous  closing  unless  fecal  extravasations  had 
occurred,  he  counselled  enlarging  the  wound  and  primarily  dis- 
covering whether  or  not  the  peritoneum  had  been  punctured.  If 
this  were  the  case  he  made  a  careful  exploration  of  the  abdominal 
cavity  with  the  finger.  If  profuse  bleeding  or  fecal  extravasation 
was  discovered  he  did  not  hesitate  to  make  as  large  an  opening  as 
was  necessary  to  find  and  remedy  the  cause  of  trouble.  If,  how- 
ever, neither  of  these  complications  were  present  he  advised  closing 
the  parietal  wound,  even  though  intestinal  injuries  were  almost 
certainly  present,  holding  that  nature  was  able  to  cope  with  these. 

Still  earlier  (1801),  Dufort  performed  exploratory  section,  but 
as  suture  of  the  intestine  was  not  then  formulated,  he  fixed  the 
wound  in  the  external  opening. 

It  may  be  claimed  that  incision  along  the  track  of  the  ball  ren- 
ders accessible  only  a  very  small  portion  of  the  peritoneal  cavity, 
that  where  a  ball  has  traversed  from  side  to  side  or  obliquely  from 
above  downward,  such  an  incision  may  be  absolutely  inadequate 
for  a  thorough  dealing  with  all  lesions.  This  procedure  consti- 
tutes, however,  no  contraindication  to  formal  abdominal.  It  is 
used,  primarily,  simply  as  a  diagnostic  means.  It  decides  whether 
or  not  the  formal  operation  should  be  performed.     In  itself  it  but 


136  WOUNDS    AND    OBSTRUCTION    OF    THE    INTESTINES. 

slightly  complicates  the  original  wound.  We  believe  with  Baudens, 
with  Stimson,  witli  many  surgeons,  that  a  wound  of  the  intestine  is 
not  in  itself  an  indication  that  the  latter  should  be  sutured.  That 
this  is  the  preferable  course  cannot  for  a  moment  be  doubted,  but 
where  there  is  profound  sliock,  where  every  moment  of  continuance 
of  operative  procedure  imperils  a  life  ah-eady  hanging  in  the  bal- 
ance, we  think  there  is  less  risk  in  leaving  these  wounds  for  nature 
to  take  care  of  than  in  unduly  prolonging  the  operation. 

It  will  be  seen  from  our  tables  that  some  of  the  operations  lasted 
between  three  and  four  hours,  hundreds  of  sutures  being  applied, 
the  bowels  being  turned  out  from  the  peritoneal  cavity,  and  sub- 
jected to  an  incredible  amount  of  handling.  Where  the  vitality  is 
already  weakened  by  severe  traumatism,  it  is  difficult  to  understand 
how  life  can  be  preserved  under  such  treatment  even  for  a  few 
hours,  and  more  than  one  case  has  perished  on  the  table. 

The  statistics  of  Keclus  and  Nogues  are  absolutely  conclusive 
not  only  as  to  the  possibility  of  cases  of  wound  of  the  viscera  by 
weapons  of  small  calibre  recovering  spontaneously,  but  also  as  to 
the  relative  frequency  with  which  this  occurs. 

Where  fecal  extravasation  has  taken  place,  as  ascertained  by  the 
exploratory  incision,  death  is  practically  certain  unless  the  gut 
wound  be  closed.  Here  the  surgeon  is  justified  in  searching  for 
and  closing  the  source  of  leakage,  no  matter  how  grave  the  patient's 
condition  may  be.  Where  there  is  extensive  hemorrhage  into  the 
peritoneal  cavity,  we  believe  that  the  formal  operation  should  be 
performed  and  the  source  of  bleeding  sought,  though,  in  one  in- 
stance where  this  was  done,  the  surgeon,  after  failing  to  discover 
and  check  the  bleeding,  finally  produced  haemostatis  by  closing  and 
tightly  compressing  the  belly  wall. 

Manier  advises  in  cases  of  hemorrhage  where  there  is  no  indica- 
tion as  to  the  vessel  injured,  medical  treatment,  compression  of  the 
belly,  ligature  of  the  extremities,  and  morphia  hypodermically. 

There  is  fortunately  in  the  treatment  of  gunshot  wounds  of  the 
belly,  not  the  same  contest  between  the  advocates  of  salines  and 
morphia  as  there  is  in  the  treatment  of  other  pathological  conditions 
of  the  abdominal  contents.  All  are  agreed  that  morphia  should 
be  given  and  given  freely  in  the  first  stages  of  these  injuries,  not 
so  much  for  its  direct  effect  upon  the  intestinal  walls  as  for  its  con- 
stitutional effect. 


SUEGICAL   TREATMENT    OF    INTESTINAL    OBSTRUCTION.       137 

It  must  be  borne  in  mind  that  every  severe  injury  to  a  segment 
of  the  gut  produces  a  temporary  paralysis  of  that  segment,  hence 
morphia  given  with  the  idea  of  checking  peristalsis  is  not  indicated. 
If  the  physician  adheres  to  the  older  method  of  feeding  by  the 
mouth  active  peristalsis  may  be  excited,  but  where  the  stomach  is 
given  entire  rest  there  is  nothing  to  inaugurate  peristalsis  until  the 
wound  is  sufficiently  advanced  for  it  to  do  no  harm. 

These  cases  should  be  fed  by  the  rectum,  should  be  stimulated 
hypodermically,  and  should  be  kept  comfortable  and  quiet  by  the 
use  of  morphia  administered  beneath  the  skin. 

It  must  be  recollected  that  fecal  extravasation  is  most  likely  to 
occur  in  the  neighborhood  of  the  external  wound,  consequently  this 
should  be  kept  carefully  under  observation,  and  on  the  first  symptom 
of  inflammation  should  be  promptly  opened,  since  by  this  treatment 
fecal  abscesses  have  been  evacuated,  which,  if  left  to  themselves, 
might  have  ruptured  into  the  general  peritoneal  cavity. 

Senn's  hydrogen  test  in  the  diagnosis  of  intestinal  perforation  is 
a  means  which  if  properly  applied  may  be  of  service  to  the  operator 
though  it  is  not  without  decided  disadvantage.  The  possibility  that 
it  might  fail  to  detect  wounds,  even  though  these  were  present,  was 
suggested  to  us  when  Senn's  paper  first  appeared,  and  we  performed 
a  number  of  experiments  which  proved  as  conclusively  as  work  upon 
the  lower  animals  can,  that  this  was  the  case. 

We  stabbed  one  dog,  making  two  wounds  in  the  ileum,  each  a 
quarter  of  an  inch  in  length,  we  then  passed  gas  from  end  to  end 
through  the  dog  without  getting  the  slightest  escape  through  the 
parietal  wound,  although  this  was  held  open.  We  shot  a  dog, 
making  two  wounds  in  the  stomach,  one  of  the  caecum  and  two 
of  the  lower  portion  of  the  ileum.  The  calibre  of  the  ball  was 
tVt5  again  we  passed  gas  through  and  through  without  having 
any  escape  from  the  wound.  We  then  opened  the  peritoneal  cavity 
and  passed  the  gas,  when  it  bubbled  up  from  the  region  of  the 
caecum,  this  wound  was  secured ;  the  bubbling  still  continuing,  we 
secured  the  wounds  of  the  ileum.  Gas  was  now  passed  until  it 
was  belched  up.  Careful  examination  showed  two  stomach  wounds 
through  which  only  by  the  insertion  of  a  probe  we  could  make  the 
gas  escape.  The  ball  had  passed  through  the  stomach  obliquely, 
making  a  valvular  opening. 

Even  though  the  gut  be  widely  opened  it  is  conceivable  that  this 


138  WOUNDS    AND    OBSTRUCTION    OF   THE    INTESTINES, 

breach  may  be  closed  by  fragments  of  food  or  of  hardened  feces. 
There  are  nearly  a  dozen  reported  cases  where  this  test  has  failed 
on  man.  It  is  readily  conceivable  that  it  may  determine  a  fecal 
extravasation  ^\liich  would  not  otherwise  be  present  or  act  as  the 
starting  point  of  paretic  distention,  which  might  have  been  avoided. 
It  is  quite  true  that  a  wound  that  would  not  allow  the  gas  to  escape 
would  probably  not  permit  fecal  extravasation,  and  if  the  surgeon 
accepts  the  teaching  that  only  such  wounds  as  are  accompanied  by 
extravasation  imperatively  demand  formal  laparotomy  the  test  may 
be  of  value.  If,  however,  he  believes  that  all  wounds  must  be  sought 
and  sutured  whether  primarily  occluded  by  nature  or  not,  he  can 
place  little  confidence  on  this  test. 

It  is  not  for  a  moment  claimed  that  wounds  which  primarily  per- 
mit no  escape  of  intestinal  contents  may  not  subsequently,  from 
imperfect  adhesions,  from  sloughing,  or  from  too  early  establishment 
of  peristalsis,  gape  widely  and  permit  extravasation  of  intestinal 
contents  with  resulting  diffused  peritonitis.  The  standpoint  taken 
is  that  the  mortality  will  be  better  if  the  surgeon  is  content  to  treat 
cases  in  which  there  is  neither  primarily  extravasation  nor  hemor- 
rhage expectantly,  reserving  the  formal  operation  for  cases  in  which 
these  complications  are  present. 

As  in  obstruction,  we  would  strongly  protest  against  evisceration, 
unless  this  procedure  be  absolutely  necessary,  and  would  urge  the 
importance  of  hastening  all  operative  details.  It  is  generally  ac- 
knowledged that  very  small  wounds  need  not  be  closed,  that  the 
first  effort  should  be  made  at  repairing  the  larger  breaches,  that  if 
resection  is  necessitated  by  extensive  laceration,  or  wound  of  the 
mesenteric  attachment  of  the  bowel,  the  quicker  operations  of 
lateral,  or  end  to  end  approximation,  are  to  be  perferred  to  circular 
enterorraphy.  In  some  instances  it  may  be  justifiable  to  form  an 
artificial  anus.  Finally  the  peritoneal  cavity  should  be  thoroughly 
flushed  with  hot  saline  solution,  and  in  all  these  cases  drainage 
should  be  established  for  twenty-four  hours.  Symptoms  other 
than  those  due  to  local  peritonitis  would  indicate  reopening  of  the 
belly  with  treatment  appropriate  to  the  condition  found.  (See 
Paretic  Distention,  Peritonitis,  etc.)  A  high  rate  of  success  can 
never  be  expected,  but  it  is  certain  that  the  mortality  now  prevail- 
ing can  be  lowered  by  proceeding  with  all  the  dispatch  possible, 


SUHQICAL    TREATMENT    OF    INTESTINAL    OESTEUCTION.       139 

and  with  the  sole  view  of  preserving  life  rather  than  of  making  an 
absolutely  perfect  operation. 

Conclusions. — Penetrating  gunshot  wounds  of  the  abdomen 
wound  the  contained  viscera  in  over  95  per  cent,  of  cases ;  in  Go 
per  cent,  of  all  cases  the  small  intestines  are  involved.  The  lesions 
are  generally  multiple. 

(2)  These  visceral  wounds  are  capable  of  spontaneous  closure 
and  healing  by  prolapse  of  the  mucous  membrane,  exudation  of 
plastic  lymph,  and  adhesions  to  neighboring  peritoneal  surfaces. 

(3)  The  common  causes  of  death  in  abdominal  gunshot  wounds 
are  hemorrhage  and  septic  peritonitis.  Though  shock  is  generally 
a  symptom  of  hemorrhage,  especially  if  prolonged  and  deepening, 
it  may,  in  itself,  cause  a  fatal  termination. 

(4)  The  mortality  of  gunshot  wounds  as  treated  by  abdominal 
section  is  not  better  than  that  of  those  treated  expectantly. 

(5)  Beyond  extravasation  of  feces  there  are  no  pathognomonic 
symptoms  of  wound  of  the  viscera,  though  bloody  vomit,  blood 
in  the  passages,  and  long  continued  shock,  suggest  that  such 
wounds  are  present. 

(6)  Internal  bleeding  may  be  diagnosed  from  shock  by  means  of 
the  hemoglobinometer. 

(7)  Wounds  of  the  small  intestines  are  more  fatal  than  those  of 
the  large. 

(8)  The  treatment  of  abdominal  wounds  with  probable  wound 
of  the  intestine  is,  enlargement  of  the  external  wound  for  the 
purpose  of  proving  penetration  and  injury  to  the  viscera.  If  no 
blood  or  fecal  extravasation  is  found  in  the  peritoneal  cavity,  the 
external  wound  may  be  closed.  If  the  visceral  wounds  are  suffi- 
ciently patulous  to  allow  of  extravasation  these  must  be  sutured, 
formal  abdominal  section  being  performed  if  necessary. 

(9)  Suture  methods  or  other  surgical  procedures  requiring  much 
time  are  contraindicated,  the  mortality  depending  directly  upon  the 
length  of  operation.  Evisceration  should  only  be  performed  when 
absolutely  necessary  for  the  speedy  completion  of  the  operation. 

(10)  Nothing  by  the  mouth  for  from  two  to  four  days ;  morphia 
to  control  pain,  stimulants  hypodermically  and  by  the  rectum,  and 
food  by  the  rectum  constitute  the  after  treatment. 


140  WOUNDS   AND   OBSTRUCTION   OF   THE   INTESTINES. 


CHAPTER  XIY. 

RUPTURE    OF   THE    INTESTINES. 

The  term  as  here  used  is  meant  to  imply  a  laceration  or  tearing 
of  the  bowel  without  rupture  of  the  abdominal  parietes.  It  may 
be  consequent  upon  severe  trauma  applied  to  this  part  of  the 
body,  or  may  result  from  blows,  jars,  or  falls,  involving  the  body 
as  a  whole. 

Curtis,  who  has  written  most  elaborately  upon  this  subject,  states 
that  the  rupture  is  really  of  the  nature  of  a  lacerated  and  contused 
wound,  the  gut  being  crushed  between  the  contusing  body  and  the 
bony  walls.     The  jejunum  and  ileum  are  most  frequently  injured. 

The  injury  may  tear  completely  across  the  lumen  of  the  bowel, 
may  produce  a  small  rent,  or  may  involve  simply  the  outer  coat. 
Extravasation  is  very  frequent,  though  spontaneous  healing  may 
take  place.  Curtis  describes  two  cases  in  both  of  which,  although 
the  bowel  was  torn  across,  the  open  ends  were  practically  entirely 
closed  owing  to  the  mucous  membrane  prolapse,  muscular  contrac- 
tion, and  adhesions  of  surrounding  parts. 

The  mesentery  is  very  frequently  involved,  and  when  this  is  the 
case  w^e  have  a  most  serious  form  of  the  injury,  since  bleeding 
commonly  occurs,  and  in  a  form  so  violent  as  to  be  rapidly  fatal. 

The  form  of  violence  which  is  most  commonly  followed  by  bowel 
rupture  is  that  which  is  severe  and  concentrated,  as  by  the  kick  of 
a  horse,  or  of  a  man,  or  by  the  passage  of  a  heavy  wheel  over  the 
abdomen. 

The  theory  of  laceration  against  bony  j)arts  would  seem  to  be 
sustained  by  the  fact  that  in  general  jarring,  such  as  comes  from 
falls,  or  from  large  bodies  travelling  with  great  momentum,  the 
intestines  commonly  escape,  the  liver  more  frequently  exhibiting 
the  effects  of  the  violence. 

Guthrie*  instances  a  case  where  the  ileum  of  a  child  was  ruptured 

1  Wounds  and  Injuries  of  tlie  Abdomen. 


KUPTURE    OF    THE    INTESTINES.  141 

by  contusion  against  tlie  thumb  of  a  person  tossing  it  up  and  catcli- 
ing  it.  At  times  the  intestinal  coats  may  be  only  partially  torn 
through,  no  extravasation  taking  place  for  some  days  when,  as  a 
result  of  secondary  sloughing,  the  wound  may  involve  all  the  intes- 
tinal coat,  and  give  rise  to  a  general  peritonitis. 

Jobert  says  that  a  person  frequently  recovers  from  the  shock  of 
an  abdominal  contusion,  but  suffers  from  pain  in  but  one  spot,  the 
rest  of  the  abdomen  remaining  in  a  normal  condition ;  there  is  here 
produced  a  slough  which  may  be  subsequently  thrown  oif  without 
harm  to  the  patient,  may  lead  to  perforative  peritonitis  with  localized 
abscess,  or  to  general  peritonitis  with  all  its  sequclse.  As  an  ex- 
ample of  this  Poncet  records  the  case  of  a  soldier  struck  in  the  left 
hyj)ochondrium  by  a  spent  fragment  of  shell.  There  was  no 
rupture  of  the  skin,  but  symptoms  of  peritonitis  developed  imme- 
diately. Opium  was  given  in  full  doses  and  the  peritonitis  was 
localized  to  the  contused  area,  the  rest  of  the  belly  being  free  from 
pain  or  inflammatory  symptoms.  An  emphysematous  tumor  with 
central  softening  was  shortly  formed,  which,  on  incision,  yielded 
fecal  matter.  The  patient  died  on  the  eighth  day.  Spaeth^  records 
a  somewhat  similar  case,  the  patient  recovering  with  an  artificial 
anus.  As  an  instance  of  how  the  intestines  may  escape  in  spite  of 
extensive  wounds,  Vaslin^  describes  a  case  in  which  the  right  flank 
was  torn  out  by  a  shell,  completely  exposing,  but  not  injuring  the 
intestines. 

It  has  been  shown  that  nature  is  equal  to  the  temporary  and 
permanent  closure  of  a  rent  in  the  bowel  even  though  this  be  exten- 
sive. Guthrie,  in  one  instance,  saw  a  patient  aged  22,  who  had 
been  run  over  by  a  carriage.  The  belly  immediately  became  dis- 
tended and  tympanitic ;  there  was  practically  no  shock.  Recovery 
was  nearly  complete  when  death  took  place  from  lung  hemorrhage. 
A  healed  rupture  of  the  small  intestines,  occluded  by  a  button  of 
omentum,  was  found.  Guthrie  states  that  apparently  some  effusion 
of  air  took  place  before  the  wound  was  plugged. 

When  fixed  viscera  are  wounded,  or  the  mesentery  is  involved, 
rapid  death  from  hemorrhage  commonly  occurs.  When  the  intes- 
tines are  ruptured,  however,  septic  peritonitis  is  the  factor  in  the 
fatal  determination. 

1  Berlin.  Klin.  Wocli.  21,  Nov.  1887.  ^  Cong.  Franc,  de  Cbirur.,  ISSS. 


142  WOUNDS    AND    OBSTRUCTION    OF    THE    INTESTINES. 

Prognosis. — The  prognosis  of  severe  contusion,  followed  by 
symptoms  of  hemorrhage,  or  of  intestinal  wound  is  exceedingly 
gloomy.  The  outlook  for  contusion  Avithout  visceral  injury, 
though  threatening  is  comparatively  favorable.  Chenu,^  out  of 
130  abdominal  contusions,  states  that  106  >vere  cured.  In  the 
Civil  War  out  of  125  cases,  but  tive  died.  Under  the  heading, 
"  Wounds  of  viscera  without  involvement  of  the  abdominal  wall," 
41  cases  are  recorded  of  Avhich  number  21  died.  Opposed  to  these 
figures  are  the  statements  of  Albert,^  who,  in  60  recorded  cases, 
found  but  one  recovery.  The  practical  experience  of  every  surgeon 
will  at  once  lead  him  to  contradict  the  truth  of  this  appalling 
mortality.  In  the  general  wards  of  a  large  hospital  it  is  not  rare 
to  have  patients  brought  in  suffering  with  the  symptoms  character- 
istic of  abdominal  contusion  with  visceral  lesions.  We  have  lately 
seen  four  of  these  cases,  two  of  w'hom  recovered  after  exhibiting 
the  symptoms  of  a  sharp  peritonitis.  One  of  the  most  striking 
instances  of  recovery  after  abdominal  contusions  is  that  narrated 
by  Fryer.^  A  lad,  after  a  blow  in  the  hepatic  region,  suffered 
from  severe  abdominal  symptoms.  He  Avas  jaundiced  on  the  fourth 
day.  Twenty-one  days  after  the  accident  there  was  great  abdomi- 
nal distention.  Thirteen  pints  of  apparently  pure  bile  were  with- 
drawn by  means  of  a  trocar.  In  the  next  three  weeks  twenty-eight 
more  pints  were  removed.     The  patient  recovered. 

Since,  in  cases  of  recovery,  it  is  impossible  to  say  whether  or  not 
the  gut  has  been  ruptured,  in  a  given  case  of  injury  of  this  kind 
the  chances  for  life  cannot  be  calculated  from  statistics.  Judging 
from  the  symptomatology  of  observed  and  of  reported  cases  we 
believe  that  the  mortality  is  not  nearly  so  absolute  as  is  generally 
believed,  yet  we  freely  grant  that  the  chances  of  recovery,  when  the 
symptoms  of  bowel  rupture  are  well  marked,  are  few. 

Symptoms. — The  first  symptoms  following  intestinal  rupture  are 
usually  those  of  shock,  though  this  may  be  entirely  absent  as  was 
noted  in  one  of  our  fatal  cases. 

Followino-  this,  extensive  abdominal  meteorism  is  the  most  char- 


1  Cong.  Franc,  de  Cliirur.,  1888. 

s  Lehrb.  der  Cliirur.,  1885,  Bd.  3,  S.  39, 

3  Medico-Chirur.  Traus.,  vol.  iv. 


RUPTURE    OF    THE    INTESTINES.  143 

acteristic  and  ominous  sign.  The  pulse  is  very  (piickly  affeded, 
becoming  rapid  and  weak,  and  either  tlie  chara(;teristic  symj)toms 
of  diffuse  peritonitis,  Math  vomiting,  constipation,  tenderness, 
thoracic  breathing  and  fever,  or  those  of  abdominal  septicajmia 
with  sub-normal  temperature  developed.  Beck^  holds  that  the 
seat  of  rupture  may  be  determined  by  local  pain  and  dulness  on 
percussion,  and  by  hicreased  resistance  on  palpation.  This  was 
particularly  marked  in  Spaeth's  case,  developing  within  twelve 
hours  of  the  original  wound. 

Diagnosis. — Since  rupture  of  the  intestine  is  an  exceedingly 
fatal  accident,  it  is  most  important  to  determine  whether  or  not  this 
has  really  taken  place.  We  believe  the  intensity  of  primary  shock 
is  misleading,  since  we  have  seen  this  condition  far  more  marked 
in  cases  of  contusion  than  in  those  where  the  gut  was  ruptured. 
Meteorism,  too,  may  be  well  developed  after  simple  contusion,  and 
may  be  complicated  by  bilious  vomiting  and  constipation. 

Where  the  vomiting  continues  and  increases  in  frequency,  where 
local  pain,  dulness  on  percussion,  and  sense  of  resistance  are  marked 
early  in  the  case,  and  where  other  symptoms  of  peritonitis  rapidly 
develop,  then  the  diagnosis  of  rupture  can  be  made  almost  posi- 
tively. The  fact  of  recovery  after  the  development  of  these  symp- 
toms does  'not  prove  that  rupture  was  not  present. 

Treatment. — When  the  features  of  bowel  rupture  as  detailed 
above,  are  present,  we  believe  that  an  immediate  abdominal  section 
is  indicated.  It  is  well  recognized  that  these  lesions  may  be  multi- 
ple, that  the  mortality  of  section  in  such  cases  is  over  90  per  cent., 
that  the  chance  is  desperate.  We  think,  however,  that  it  should  be 
taken  pi^ovided  the  characteristic  symptoms  are  present.  In  the 
absence  of  these  symptoms  expectant  treatment  is  indicated.  In 
any  case  morphia  and  alcohol,  particularly  the  latter,  and  in  full 
doses,  are  indicated.  Absolutely  nothing  should  be  given  by  the 
mouth. 

In  cases  characterized  by  deepening  shock  we  should  endeavor 
to  exclude  hemorrhage  by  means  of  the  haemoglobinometer,  and 
by  careful  palpation  and  percussion  of  the  abdomen.     If  still  in 

1  Deutsch.  Zeithschr.  f.  Cliirur.  Bd.  15,  S.  14. 


144  WOUNDS    OF    THE    INTESTIXES. 

doubt,  tlicre  should  be  no  hesitation  in  making  a  small  median 
exploratory  incision,  since  this  would  add  but  little  to  the  gravity 
of  the  case,  and  would  at  once  decide  whether  or  not  Weeding  were 
present.  In  cases  of  internal  hemorrhage,  no  matter  how  desperate 
the  patient's  condition  an  effort  should  be  made  to  secure  the  torn 
vessel. 


SECTION   FOR   GUNSHOT   WOUNDS. 


H5 


m  O 
8Ph 


C  a  5  a 


t.  ;-'  1-  oj 


o.fl.2  q.; 


OtH  JJ' 


fl  o  '^  fl  a,= 
p  O  ?  0)  m 


ft 


d  l;  <=    jLi 


(5^ii 


<L  -^         -7- 


£a    9 

^  2  3,2  a 


o  rt  i 


-=S      =      s 


a^  S  i) 
^  i'  « 


o   -- 

9  s 
gel 


-  o  o 
",2  « 


OS  g  3  c  01 


P  ■-«     -S  ? 


»  qtS     ^  o 


P>  g  o>  a,-rt 
o  cj  g  oj  a 


miu 


^'^ 


'    CJ 


V 


.2  « 


a  a  a     §  *  °  2 
S  «  ^  .2  a  o  g 

oo^ga.S?S 
^-^  .-■S  "-"3  ",2 

£  SP.3  ft 


-s      o_o 


tn 


a  s  o  a'=''S 
2  a<2  S  a  o 

a  g  '^  o  js  s 
a  =2  -X  :§  &: 

a     .:i,   ,i=-^ 

a  o«=i;      ^ 

o  ii  a!,°  a    -■  . 

fe  +J-"  -  o  a  t< 

_rr     BacDs<"     -- 

;§ir-.2&5a    S:::,^ 

^^         -tJ-MOt^  -'—JO 


-  °  --SI 


g-Sa 


o  o.s 
o5s 


<u  ra  o  ,o     a  .n  .s 


a;  o 
;/=  a 


a  oj  o 
a  M)C 


cs  cu 


-3  .i:  •+-  K  ^  a; 


O    tn 


l^^-^ai'2'S 

=-'  •"  d  9  c  !=     ^ 

^'"g  =  ^'^"^ 
.  a^B     •'^  ons  •- 
o  a  a  -t:="  ,-.  c  oj  .- 
'3g=saos§ga 

•^   P         C3  to  .^   O  "  _0  ' 


-Sa-S 
,Q  a  a 
c«  o  <u   . 

©  •-.-     <o 
•--  ^  ft-°  ^ 


iJ, 


"  °  S  ' 

a-s  - 

O    p    M 


^  S22c 
<D  a  .a ."  a 
>  a"-S  P 

-g-g  2.3  r 
c  °  ^0,2  3 

>r^     a  r—     '^    ^ 

ISSa^a 


r5.2,-l  aiM  o 


'-'  ^  ' 

*<  a  jH  M  2 

>  H  w  &<  S 

S  R  ^  fi  5 


:^ 


CO  "  m  ij 


"*l  <CB 


a^ 


r—  aj  aj< 


Sh,  00 

3  1^1-1 


10 


H 
^  a 

(K    O 


.l^_ 


r-^  a 

OJ   ^  .1 


tj  a  cu  J-  a  in  » .^  ii  bb 


-=1 


a  »5 


.  ■visit 


146 


SECTION   FOR   GUNSHOT   WOUNDS. 


tao 


V-      =  -  S  xja 

TS  —  "-^  J!  —  a*  "^ 
3  SS-B  >.,[».—-'  3 

•^      <u  o  5  «  " 


c  i  -  o 


Q  o  a 


^  =  §  i^.a 

'^  ^  ^  -.  ® 


5  -^^    r-  t- 


O    Ci   C    O 
*-   3   D  <- 

S  _, "".  'S 

.2  Sh\=  o 

ii  ■"  (=  =^ 
.;==„<="•-  o 

.  c  •-'=  = 

•-  g;  ^  ?  N 


g  £  «-5  2 
•r:  g.s:jg  g. 

»       ,[S  o  CO 
3  r=  CJ  ^  2 

'"  S!2  o  fl 
"2  ■  --2  rt  "^  ■-= 
~  ?~  S  t-i  > 


'5b 


■  5  =  3  ^'  ^  S 


'  6  AC'Zl 


-SL-ir^j-i^sT 


p=  %H  -£  P  T  ^     "S 


-  o. 


f'  M.="  C"   ;l'S 


!«=  o-a  =  ^  a 


Oi  I.   ^ 


o 


^  ^  b  fc  >^ 

C  s  K  ?:  o 

K  >  ^  O  ^ 

^  H  ^  Q  ^ 

z  fcJ  S  »  « 


S-ss 


■^  S  3  a 
<u  o  o,2 


S-So' 


P  5"  3*  ^*-' 

3 'S^'^ 

§■303  5 

—  o  o  fe 
r;  cs  0)  .-■! 


a3^oSg-o.g^-g 


-  a     ' 


•S  <j  "^  '^     13  o 


a  a  -      o  J- 


g.  cr. 


o  a  5  S.:=  fe  :a 


0.5  3>^  5  o 


rr-r 

OQ 

aj 

■3 

r=5 

aj 

■r) 

cS 

rt 

fi 

<r', 

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s 

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1 

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m 

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SUCTION   FOR   GUNSHOT   WOUNDS. 


147 


air  Sg  SI'S  £«l^- 


m  O 
DPh 


CO  e! 
a2 


.S  ft 


1   odd 


3  oj  g  o 

TSO        .^ 

Cog 

-  »  a  2  w) 
S  rt  03  '43  a 
.2d      « a 


P  o  o 


^    O    S 


§53     ^ 


^-d 


gT3   1 

"5  2  J 


c        r  5^*=-= 


a?       St! 


as 


1^    Zj 


■9«a 


1° 


4<(  H 

13 


"ra 


o       _■-;■-! 


3^5  5  =3  a 


j^ia  cs  crf-'a.i: 


^|°-£ 

"^  o  cu.S 
a  c  •  -  n  -j; 
g  5  =3  ■-«  ^ 
"S^n  o  S  a 

j2  0=w-«.„ 


jaS  a  rt 
_bc2.2  2 

o  2  i:  i 
P  o  §3  o 

"s.sia 


o  a 
a  a 

o  ® 


'a  cs 
a  ^-d 


S  a     -^3 


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■t:  ^  =2  '-S  'd  _g  %;  ^ 

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s  ^  a: 
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5§ 


as&H 


W  5  B) 


l5  '^ 


SPhS 
p; 


O  3 


3^ 


SS-K     ^gja     ixTg^ 
M  H  pq 


148 


SECTION    FOR   GUNSHOT   WOUNDS. 


V,  to 

K  'J 

K  O 


g«5 


•-S  "* 
boo  S 

o  CS 

.-S-H   o 

■g  c  o 


■2i:  be 


•r^  .:3  -a     i=     '-■  ^   +J  Q,  s  •« 


"o-;o=— ^?— a 


c  >  °  -^  "I  = -^  £  1  -^  "".  i 
"S-w  £  "Si;  g  g  =  S  3^  I 


Ots 
■-^  bO 


"3  i"^ 


s  §  a 


^  s  5  a  =  <u 


;-  o  3 


-■S  Sr* 


S3 


S  5  =3 


-3 

p 
o 

bc 

OS 

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3 

c 
o 

5 
ft 

> 

P 

be 

a> 
3 

o 

2  2 

o 

5 
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c 

ti 

o 
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p 

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0) 

< 

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1 

o 

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s 

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3  a 

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tH 

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0) 

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p. 

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(b" 

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o  5'E  aj  -  ? 

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3  0^.  SSg 

^    CS  .S  ™  73   tH 


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■^l  3'"  3  ^ 
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i.2.S 

i  o'a 


3     - 


^  a;       oj  ^  o 


ftS 


;  ft^  a  "  " 

I.  a>_,  o  o  ft 

'  o  c  '2  -a  a  - 

:  J3  cS  S  3 

;  S  3  g  O  S 
;  boo  Pt-'a 


S-^-fk 


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r-    ?    O 

'^  o  > 


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H 


fi< 


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o  c 


Sil 

S  ?  a 


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a)  a 


EMWr 


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"qChi-:  CO 


p   3   gci 


SECTION    FOR   GUNSHOT   WOUNDS. 


149 


»     - 


So  u 


9 


O  0,5 
h   S  03 

a)  o-s 


0)  ja 

«  OJ  o  ._g 

■^  o 

rfl     OJ     0)     «   ■« 

*^A  hfC  3 

Phoo 

5  5 


;i3        O 

-tt  --o 


fl  P  a 


-^"s 


0  0.-5=^ 
-Jog 


O   O        '^ 


a;  o 

O  o 

oq 


^  w       S 


a2  3.i 


sa 

.  S  =*  .2  «>  - 


.3  •-     ^ 

-3        ^ 
■«   O         O 


o  S 


C^-S 


^  -^S  ,S  a  .S  hJ  -^  3 


a  2-13 
'  .3  fl 


(U"*  c!  M  s- 

&0O  c-3  <= 

.as*-  ^o  S 

S  •«  •^..'p  li  g 
a  Mit:  «  s.a 

ens'?  ="•^.3 

o  2  §  -2  c  o 

O  m  "«  ^  3  ?n 
.rt  (U  O  3  g.2P 


2§ 


g^ni  ;>  a  i>>tH 


ftS 


oo  1.2  =3  « 

h^  00  +J  .^  't^ '7^ 


.^■^  M  o 
9S "^  S 
ftTLoj .- 

^  o'Ti:  CO 
.30  g^o 


g  S  fl 
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"■^  2  5 

all^ 


=  0,2  =*  a' 

.  ..3  ft*^  +2 
Pa     ^-  =« 

3      a=n » 
=  S-S  do 

u^  o  §  o 


Oo 


Mo 

^  3^  P 

^  ft'=»c; 

0-2  a  §1 


11  5-"""^  = 


.a  §•' 


^  a-  M  j„ " 

^  S  OTiT3„ 

ta     -^  a  a  =« 
c!  o  a  3  3  fl 

tSr-i" 


g^^« 


I  a 


H 


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.ti  bc^  a 


5  C3^^  S.3  a  „ 
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>'^'*^'2,  &"=«  §  a 

;  '^ ^  boc  a.5co 
^  £  aj '-'    ..'^  a  --a 
<o."S®S32o 


a  a  -^  *  ^  r^ 

;g^  °ri  3-" 

a  fl-s  g  ^'^  i 
o    r  3  "  ^     •■ 


^  ^ a  ^ 

o  boa's  3  • 
■«  ci  — I  "  .~  * 


w  Sh  g  ;?■ 
^  S  «  S 


^ 


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So  PH 
CO       H  iJ 


a-s 

W  0  X 

0 

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in 

t<  01 

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CO 

0 

0.  ■   - 

.   0)  w 

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bb 

2^S 

m 

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w 

.      w  . 

fp 

m 

150 


SECTION   FOR   GUNSHOT   WOUNDS. 


v:  O 

a  OS 


l.z 


>.bot; 


<orZi 


oa|o^a 

5  =  2^;5o 


M    f 


g 

«3 


..:i^^ 


a^s    oo 


-•  =5^ 


.,.„.-.  o  a  „  t»>i>>.i: 

;  cj  a>  ti  ^  S  o 'C  S 
o  «  5  h-^  o  ^  .£ 


a  IS 

oja  &.a 
~c<i  a  a 


to  ft'-S  r^  P  c.)  "o  5 


go 


ity  not 

e  quan- 
ity  and 
testine. 
.   long; 
n  cav. ; 

embert 
oniach ; 
• ;  3  sii- 
trance; 

^sful ;  2 

h  3  in. ; 

opera- 

perito- 
ed   out 
•ide  so- 
ratioii 

IS 

o       g  Ot.^       boa 

Median  incision  ;    L 
sutures  (silk)  to  st 
large  catgut  to  live 
turestowoundofen 
4  to  wound  of  exit. 

Hydrogen  test  succe 
excisions  of  gut  eac 
Lembert    sutures  ; 

ence  of 

y  wash 

"bichlo 

of  ope 

a-a 
o  a 

in. ;   peritoneal 
cleansed. 

Section  ;  conside 
tity  of  blood  in 
a  doubtful  wd.  o 

Med.   incision    4 
large  hemorrha 
time  1  hr.  55  mi 

o 

Si 

CO 

c 

Section ;  evid 
nitis  ;    cavit 
with  1-10,000 
lution  ;  time 
2  hours. 

£>a 

3  a 

u 

a-a 

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a  a"TS 

a  S  a 

w  a'  3 

S  o  o 

a  a  IS 


5  Srt 


^         "q 


00  O  • A 

<^.;g.5  a  S 

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o5  '-<  •  - .  -^ .; 

S  si's  a  o.t: 
S  o  ci  s  - 
S,  bo  a.S  ^ 


o  a  § 


_bo.~ 

'E.S 


aa 


B"^  bo 

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g  _0  IM        ^  O  I 


bo 


"3  a  2  a  " 

a'lL  r-'o'd 

^ob 

o  ^  >< 


-§■§3^ 


ai^ 


•B'^ta     « 2 


11:  I  2-1 


=s  2 
a3 


a  a 


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cd 

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a 

«M 

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c 

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rt\ 

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5  «  ^  ?  >5 


ft  ^ 


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hS 

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fe  •-; 

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a. 

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a  "       •  cj  _•  «>  oj .-  _.  ^  '^  _•  i-h" 

S    .0)00  -TO)     -Cgcp    ~2  s-^ 

5  CC    fc.  rt   g  r^  (M    3  i-l  1^  rH    c8  <;  K- 

o  u        o  ft 


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to  . 

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bo<;" 
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5  3  a 

ar'"  J 


^00 


SECTION   FOR   GUNSHOT   WOUNDS. 


151 


5  « 
K  q 


.S  o'S  a!  « 


^  Es  ^  -C^  ,^ 


^  9  s's 


I  fl  ?  a  <".:: 


,!-    tn    d   S   3 


1)  i    i 

"g  ol  p  5  a.; 


«      .rt  be      ■- 


r  £  *    • 


2&S 

Ph   "^ 

Si 
O 

□  --a 

't3  S'" 
I  o  P  o 


3°-3|§-9 

i  .t-   n   :3   ni  ^ 


.2  ^  i;  a  °  rt 
o<ri  p  j'3t„ 


'S  u"?  s^ «  P 


,2  9  >>  '§  s  a 


pns  Vs  &o 


o  T  t^ 

C-°    CD   O    --S 
•"S    m"*    ..'«    °    ! 

3.2  S  p  ©  bcg-jj  i 
_  S  o  C 


r:, 


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o  s  --^3 

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a  ^ 

MI'S  S  ft 

g  «  a  o 


rSr 


■-2  "  S !« 


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CO  p.a 


a  p-  ,a  -S 

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~a? 


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CHESTS 

<.S  a  a 

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h2?^ 


=  a  .=,  ° '" 
ST  2  a' «  > 

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p  _o  S  ®  ft 
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a5  ="-2 

S  -•  ^  ^^ 


g  «^ 
a.2° 

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a  §  o 


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f^    CD    1^  T 


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o  -B  ?:  5  a 
a  o  ^  S 
o  o  -g  -^ 
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CD 

a2l5 

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C^-~ 

a  a' 

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k-.-3 

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ga 

29 


fi^ 


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a-^t- 


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ft 

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a      a  t^  ^  — ■  c» 

cd  .  •  o  cac  bJO  a  00 


152 


SECTION    FOR   GUNSHOT    WOUNDS. 


&« 


■«  = 


■-I  ^^ 


„  .  (M     a    K  5^    r;    i 

S'^'d'^  S'C  o  an 

cs  el's  i--'-'S'r 
^■2  o  §  o  S  ^r-^ 


g3:go2.2 

O^t;  q  <U  03 


S.Q  S""  i^-n 

I  £:-.•§  a-S  o 


o  a  ^-'  r^   ^ 

a  3  Sf-a 


'^   OJ    ^ 


«  s 


1    Oi   Ph 


as 

S  a  S  S 


-^  ^  «^  tc  o       I 
a      u  ^  a  tn  a 

-^  S-B  g-S  a 

a  p  2  ?  a  ns  « 
'"  o  S  "  '^  a  .2    . 

■5  !"  S  a  o  8) 


o 


.o  1;  Gj  a;       ci( 

a  K^.^-s  o 

^-  a  ^  .S  °  a 

c  tu  cs  "3.2   . 
.2  g  .-S  a  o  i  a 

a    >    a;    fcH  r-t    C3  CC 


_  !-  .t;  a ' 
a  a  o' 


.5'io 

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3 1  S     ■ 

o  a  £■.£> 


a  ?; 

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is 


o  a  2 
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^  o  p 


s  o 


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SS      IH 


o5 


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ts  a  g     « 

»        -g   . 

CJ--;  0  3  g 


rt  a  o  «  2 

3.2  m=S.:3 

o2  S  3  •-=« 

S  •-  -t^''  a 

C3    0)—    !h    "   ^ 


gj 


QJ 


5  S.O  m  o  „ 
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a  a  „ 


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v^  -§  fe  a  o 

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a  -*-^  ^  a  Qj  g 

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rever. 

Deut. 

Wosch 

18SG. 

■iuk,  A 

Phila. 

Times, 

459. 

aston. 
Med.  a 
Eept., 
June  1 
vol.  54 

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0 

0 

SECTION   FOR   GUNSHOT   WOUNDS. 


153 


w 

Died. 

Eecov'd. 
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BETWEEN 
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1                                                            Jk^               CO                                                 1                       CO                                  CO 

w  p  «■ 

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11 


154 


SECTION   FOR   GUNSHOT    WOUNDS. 


t-   t«   3   5 


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«  a  £ 

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cp  CD 


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9  rt'=^ 
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g    C3    a 
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3    C3    S    S    tH 

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c3  -"  ■K'S  5' 


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SECTION   FOR   GUNSHOT   WOUNDS. 


155 


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Lutz,  F.  J. 
Annals  of 
gery,  VII., 
91. 

.2_:  =^ 
a:  5  5 

156 


SECTION   FOR   GUNSHOT   WOUNDS. 


55  to 


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SECTION    FOR   (jIUKSHOT    WOUNDS. 


167 


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158 


SECTION    FOR   GUNSHOT   WOUNDS. 


p 

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SECTION   FOR   GUNSHOT   WOUNDS. 


159 


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Amer.  M 
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SECTION   FOR   GUNSHOT   WOUNDS. 


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SECTION    FOR   GUNSHOT   WOUNDS. 


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SECTION   FOR   GUNSHOT   WOUNDS. 


163 


Died. 
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164 


SUMMARY   OF   SECTION   FOR   GUNSHOT   WOUNDS. 


SUMMARY  OF  THE  TABLES  OF  GUNSHOT  WOUNDS  OF  THE 
ABDOMINAL  CONTENTS.! 


Gunshot  womids  of  abdomen 

Result  not  determined 

Mortality  of  129  cases 
Wounds  of  small  intestines  only     . 

Recovered  12.      Died  36.      . 
Wounds  of  small  and  large  intestines 

Recovered  10.       Died  4. 
Wounds  of  large  intestines  only 

Recovered  3.      Died  5. 
Wounds  of  stomach  only 

Recovered  1.      Died  3. 
Wounds  of  hollow  viscera  (stomach,  intes- 
tines, and  bladder)    . 

Recovered  2.      Died  13. 
Wounds  of  solid  viscera 

Recovered  5.      Died  7. 
Wounds  of  solid  and  hollow  viscera 

Recovered  3.      Died  9.  . 

No  visceral  wound 

Recovered  6.      Died  2. 


130. 
1. 

48. 

14. 


4. 


15. 


12. 


12. 


8. 


66. G  per  cent.  (86  cases). 
Mortality  75  per  cent. 
Mortality  28.6  per  cent. 
Mortality  62.5  per  cent. 
Mortality  75  per  cent. 

Mortality  86|  per  cent. 
Mortality  58^  per  cent. 
Mortality  75  per  cent. 
Mortality  25  per  cent. 


TIME  INTERVENING  BETWEEN  THE  INFLICTION  OP   THE  INJURY  AND 


SURGICAL  INTERVENTION. 


Two  hours 
Four  hours     .     . 
Eight  hours    .     . 
Twelve  hours 
Twenty-four  hours 


24. 

20. 

21. 

7. 

22. 


Recovered  11. 

10. 

3. 

3. 

3. 


D 


After  twenty-four  hours    11. 


ied  13. 
"  10, 
"  18. 
"  4. 
"  19. 
"       9. 


Mortality  54^  per  cent. 
50 
"         81.8      " 
57.1      " 
86.3      " 


81.8 


TIME  INTERVENING  BETWEEN  OPERATION  AND  DEATH 
Two  hours 
Four  hours 
Eight  hours 


8  cases  (shock  or  hemorrhage). 
2      <(  a  u 

8     "      (shock  or  hemorrhage,  except  1  from 
peritonitis), 
(shock,  hemorrhage,  and  peritonitis). 


Twelve  hours    ...       6 
Twenty- four  hours    .         .     13     "  "  "  "  " 

After  twenty-four  hours    .     32     "      (peritonitis,  intestino-peritoneal  septi- 
caemia, hemorrhage). 

Death  within  twenty-four  hours  is  usually  due  to  bleeding  or  shock. 

Death  after  twenty-four  hours  is  usually  due  to  peritonitis. 


1  In  preparing  the  preceding  table  we  freely  consulted  the  statistics  of  Coe 
and  Morton. 


SUMMARY   OF  SECmON    FOR   GUNSHOT   WOUNDS. 


1C5 


TIME  CONSUMED  IN  OPERATING. 


One  half  hour        .     . 

2 

cases.     Recovered  1. 

Diec 

1  1. 

Mortality  50  XJer  cent. 

One  hour      .     .     .     . 

4 

3. 

1. 

25        " 

One  and  a  half  hours 

(3 

4. 

2. 

33^     " 

Two  hours    .     .     . 

8 

2. 

6. 

75 

Two  and  a  half  hours 

3 

1. 

2. 

GO?,      " 

Three  hours  or  more 

5 

0. 

5. 

"         100        " 

CALIBRE  OP  BULLET. 

Shot  by  No.  22  bore. 

10  cases.     Recovered  5. 

Died 

5. 

Mortality  50  per  cent.- 

32     " 

2(i 

'*        10. 

" 

16. 

01. 5    " 

«'        "        38     " 

17 

"                  "9 

i( 

8. 

47 

it          (<          44      a 

5 

u                       <<            I 

(1 

4. 

80       " 

Intestines  resected  10  cases.     Died  10. 


Mortality  100  per  cent. 


The  tabulation  also  shows  that  multiple  wounds  and  profuse  internal  bleeding 
may  be  accompanied  by  very  slight  shock  ;  that  comparatively  slight  wounds 
may  pi'oduce  profound  shock.  The  mortality  in  cases  of  severe  shock  is  about 
90  per  cent.  In  cases  of  moderate  or  slightly  marked  shock  about  the  same  as 
for  intestiiaal  wounds  in  general. 


INDEX. 


ABDOMEN,  ice  to,  for  obstruction,  105 
puncture  of,  in  obstruction,  107 
Abdominal  massage  in  obstruction,  104 

section  for  obstruction.  111 
Acute  peritonitis,  symptoms  of,  68 
Atresia  of  oesophagus,  19 


BELLADONNA  in  obstruction,  90 
Blood,  general  evacuations  of,  in 
intussusception,  33 
Body  heat  in  obstruction,  97 
Bullets  in  treatment  of  obstruction,  106 


CHRONIC  intestinal  obstruction,  18, 
63 
Classification  of  intestinal  obstruction, 

17 
Colotomy  for  obstruction,  110 
Complication  of  abdominal  section,  121 
Conclusions   as   to  gunshot  wounds  of 

intestine,  139 
Concussion  of  intestines,  141 
Congenital  malformations,  19 
Constipation  in  volvulus,  49 


DIAGNOSIS  of  gunshot  wounds  of  in- 
testine, 129 
of  intestinal  obstruction,  81 
of  intussusception,  35 
of  obstruction  due  to  foreign  body, 

55 
of  obstruction  of  intestine,  21 
of  peritonitis,  72 
of  rupture  of  intestine,  143 
of  volvulus,  50 
Distention  of  abdomen  as  a  symptom 

of  intussusception,  34 
Diet  in  obstruction,  90 
Diffuse  septic  peritonitis,  67 


ELECTRICITY   in    treatment   of   ob- 
struction, 94 


End  to  end  approximation,  116 
Enemata,  treatment  of  obstruction  by, 

91 
Enteroliths,  obstruction  from,  54 
Enterostomy  for  obstruction,  108 
Ether  in  treatment  of  obstruction,  106 
Etiology  of  intestinal  paralysis,  57 


FOREIGN  bodies,   obstruction  from, 
52 


G^  ALL-STONES,  obstruction  from,  54 
IT     Gaseous  injections  in  treatment  of 
obstruction,  95 
General  peritonitis,  66 
Gunshot  wounds  of  the  intestines,  122 
diagnosis  of,  129 
prognosis  of,  131 
treatment  of,  133 


H 


EAT,  bodily,  in  obstruction,  97 


ICE  to  abdomen  for  obstruction,  105 
Ileo  colostomy,  118 
Injections,    gaseous,    in    treatment    of 
obstruction,  95 
of  ether  for  obstruction,  106 
in  treatment  of  obstruction,  91 
preparation  of,  in  obstruction,  102 
Implantation,  118 

Internal  strangulation  of  intestine,  40 
Intestinal  obstruction,  17 
diagnosis  of,  81 
prognosis  of,  85 
paralysis,  57 

prognosis  of,  159 
rupture,  treatment  of,  143 
symptoms  of,  60 
Intestine,  rupture  of,  142 
Intestines,  gunshot  wounds  of,  122 
prognosis  of,  131 


168 


INDEX. 


Intestino-peritoiieal  septicaemia,  68,  70 
Intussusception,  28 


LATERAL  apposition,  116 
Lavage,  treatment  of  obstruction 
by,  91 


MALFORMATIONS,  congenital,  18 
Massage,   abdominal,   in    obstruc- 
tion, 104 
Medical  treatment  of  peritonitis,  76 
Medication  in  obstruction,  i^0 
Meteorism  in  volvulus,  49 
Mercury,  metallic,  for  obstruction,  105 


OBSTRUCTION,    abdominal    section 
for,  111 
belladonna  and  opium  in,  90 
bodily  heat  in,  97 
chronic,  63 

treatment  of,  64 
colotomy  for,  110 
diagnosis  of,  21 
diet  for,  90 

enteroliths  as  a  cause  of,  54 
enterostomy  for,  108 
from  foreign  bodies,  52 
from  gall-stones,  54 
gaseous  injections  in  treatment  of, 

95 
ice  to  abdomen  for,  105 
injections  of  ether  for,  106 
t      mercury,  metallic,  for,  105 
posture  in  treatment  of,  106 
prognosis  of,  22,  64 
puncture  of  abdomen  for,  107 
salt  solutions  for  relief  of,  102 
spasmodic,  63 
surgical  treatment  of,  107 
symptoms  of,  20 

treated  by  abdominal  massage,  104 
treatment  of,  23 
by  bullets,  106 
by  electricity,  94 
by  injections,  91 
Old  age  as  a  cause  of  volvulus,  50 
Operative  treatment  of   intestinal  ob- 
struction, 86 
of  peritonitis,  73 
Opium  in  obstruction,  90 


PAIN  in  volvulus,  49 
Paralysis,  intestinal,  57 
Pathology  of  obstruction  due  to  foreign 
bodies,  54 
of  strangulation,  42 
of  volvulus,  48 


Peritonitis,  66 

acute,  symptoms  of,  68 
diagnosis  of,  72 
operative  treatment  of,  73 
-treatment  of,  73 
Position  in  treating  obstruction,  106 
Preparation  of  lic^uids  for  injection  in 

obstruction,  102 
Progressive  suppurative  peritonitis,  66, 

74 
Prognosis  of  chronic  obstruction,  64 
of  intestinal  concussion,  141 
obstruction,  22,  85 
paralysis,  59 
of  intussusception,  35 
of  gunshot  wounds  of  intestine,  131 
of  obstruction  due  to  foreign  body, 

55 
of  volvulus,  48 
Puncture  of  the  abdomen   in  obstruc- 
tion, 107 


RUPTURE  of  intestine,  diagnosis,  142, 
143 
treatment  of,  143 


SALT  solutions  for  injection  in  obstruc- 
tion, 102 
Section,  abdominal,  for  obstruction.  111 
Senn's  modification  of  Jobert's  invagi- 
nation, 116 
Septictemia,  intestino-peritoneal,  68,  70 
Strangulation  of  intestine,  internal,  40 
pathology  of,  42 
treatment  of,  44 
symptoms  of,  42 
Spasmodic  obstruction,  63 
Surgical  treatment  of  intestinal  obstruc- 
tion, 107 
Summary  of  subject  of  intestinal  ob- 
struction, 27 
Symptoms  of  acute  peritonitis,  68 
of  internal  strangulation,  42 
of  intestinal  paralysis,  60 
of  obstruction,  20 

due  to  foreign  body,  55 
of  rupture  of  intestine,  142 
of  volvulus,  49 


TEMPERATURE  of  body  in  obstruc- 
tion, 97 
Tenesmus  in  intussusception,  33 
Treatment  of  chronic  obstruction,  64 
of  gunshot  wounds  of  intestine,  133 
of  intestinal  paralysis,  61 

rupture,  143 
of  intestino-peritoneal  septicaemia, 
75 


INDJOX. 


J  GO 


Treatment  of  intussusception,  SG 
of  obstruction,  23 
by  bullets,  10(j 
by  enemata,  91 
by  ether,  100 
by  massage,  104 
by  lavage  of  obstruction,  1)1 
due  to  foreign  bodies,  55 
peritonitis  medical,  71 
posture  in,  106 
of  progressive  suppurative  perito- 
nitis, 74 
of  peritonitis,  73 
operative,  73 
of  strangulation,  44 
surgical,  of  obstruction,  107 
of  volvulus,  50 
Tumor  as  a  symptom  of  intussuscep- 
tion, 34 


yOLVULUS,  47 
V         constipation  in,  49 

diagnosis  of,  50 

meteorism  in,  49 

old  age  as  a  cause,  50 

pain  in,  49 

pathology  of,  48 

prognosis  of,  48 

symptoms  of,  49 

treatment  of,  50 

vomiting  in,  49 
Vomiting  as  a  symptom  of  intussuscep- 
tion, 33 
in  volvulus,  49 


WOUNDS  of  the  intestines,  gunshot, 
122 


treatment  of,  133 


12 


DEC  IE 


V^.li' 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsLstx) 

RD  540  IVI36  C.1 

The  surgical  treatment  of  wounds  and  obs 


2002246562 


